KEMENTERIAN KESIHATAN

MALAYSIA

TECHNICAL SPECIFICATIONS
HOSPITAL PERFORMANCE
INDICATORS FOR ACCOUNTABILITY
(HPIA)
MEDICAL PROGRAMME

2025
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

LIST OF HOSPITAL PERFORMANCE INDICATORS

FOR ACCOUNTABILITY (HPIA)
HPIA Element Indicator
1 Health (Clinical Outcome) 1-3
2 Health (Quality Care) 4-7
3 Responsiveness 8-11
4 Fair Financing & Governance 12-14

NO INDICATOR STANDARD PAGE

HEALTH (CLINICAL OUTCOME)

≤10 death
cases per
1000
1. # Rate of Severity of Illness (SOI) 1 Death cases per 1,000
patient 4
Severity of Illness (SOI) 1 Discharge Home cases
discharged
home (SOI
1)
2.
# Index of unplanned readmission ≥1 6

3.
# Index of Patient Fall ≥1 11

HEALTH (QUALITY CARE)

% Performance of Patient Safety Incident Reporting and
4. Learning System and Root Cause Analysis and Action Plan
≥ 70% 14
(RCA2) for Actual Patient Safety Incidents Resulting in
Severe or Death Outcome in the corresponding year
# Index of paramedics who have a CURRENT trained
5. status in Basic Life Support (BLS) in the corresponding year
≥ 0.9 19
A: acute care area
B: non acute area
6. % of fire drill that has been carried out by the hospital in
100% 22
the corresponding year

7. % of clinical department conducting clinical audit in the

≥ 30% 23
hospital/institution in the corresponding year

RESPONSIVENESS
Please refer
8.
% of Hospitals Achieving the Specified Bed Waiting Time technical 25
specifications
9. % of patients with waiting time of ≤ 90 minutes to see
≥ 90% 28
doctor at the Specialist Clinic
10. % of workplace inspection performed quarterly in the
100% 30
corresponding year

1 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

NO INDICATOR STANDARD PAGE

11. % of hospital or medical institutional staff undergo health
≥ 70% 32
screening for risk of non-communicable disease (NCD)
FAIR FINANCING & GOVERNANCE
12.
% of bills payment within 14 days ≥ 99% 34
13. % of assets in the hospital that were registered within 2
100% 35
weeks
% of new hospital staffs who attended the Orientation
14.
Programme within 3 months of their placement at the 100% 36
Unit or Department in the hospital

SATELLITE INDICATORS
*** Satellite indicators encompass indicators from State Health Directors KPIs or any top
management’s KPIs that need to be monitored by the hospital director. It is important to
note that these indicators will be changed annually. Kindly refer to the respective technical
specifications for each KPI.

INDICATORS STANDARDS

State Health Director KPI 2025

1. # Purata Performance Indeks Jangkitan Aliran Darah berkaitan
Penjagaan Kesihatan (bacteraemia) ≥ 1.00
(State Health Director KPI 2025)
2. % Bayi Baru Lahir yang Menjalani Saringan Pendengaran
(Universal Newborn Hearing Screening) dalam Tempoh 28 Hari
≥85 %
Selepas Kelahiran di Hospital/ Fasiliti Kesihatan Kerajaan
(State Health Director KPI 2025)
3. % Peralatan Perubatan/ Sistem Kejuruteraan Fasiliti Mencapai
Uptime di Bawah Perkhidmatan Sokongan Hospital (PSH) ≥95 %
(State Health Director KPI 2025)

Deputy State Health Director (Medical) KPI 2025

1. # Indeks Pencapaian Petunjuk Prestasi Utama (KPI) Kualiti

Perkhidmatan Perubatan Klinikal ≥ 0.9
(Deputy State Health Director (Medical) KPI 2025)
2. # Purata Performance Indeks Jangkitan Aliran Darah berkaitan
Penjagaan Kesihatan (bacteraemia) ≥1
(Deputy State Health Director (Medical) KPI 2025)
3. % Bayi Baru Lahir yang Menjalani Saringan Pendengaran
(Universal Newborn Hearing Screening) dalam Tempoh 28 Hari
≥ 85%
Selepas Kelahiran di Hospital/ Fasiliti Kesihatan Kerajaan
(Deputy State Health Director (Medical) KPI 2025)

2 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

4. % Hospital yang Mencapai Bed Waiting Time yang Ditetapkan

(Deputy State Health Director (Medical) KPI 2025) ≥ 80%

5. % Keputusan Lembaga Perubatan Selesai Bersidang dalam

Tempoh Masa yang Ditetapkan ≥75%
(Deputy State Health Director (Medical) KPI 2025)
6. % Jururawat yang Bertugas di Penempatan Klinikal > 6 Bulan
Diperakui Lulus dan Mendapat Privilege ≥ 80%
(Deputy State Health Director (Medical) KPI 2025)

HOSPITAL REPORT CARD

CONTENTS PAGE
1. Weighted Percentile – Point – Scoring Concept (PPS-C)
41

2. Cluster Hospital
43

3. Casemix
44

4. Patient Satisfaction Questionnaire -18 (PSQ – 18)

46

Clinical Performance Surveillance Unit (CPSU)

Medical Care Quality Section
Medical Development Division
Ministry of Health Malaysia
Tel: 03-88831180
[email protected]

3 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

# Rate of Severity of Illness (SOI) 1 Death cases per 1,000

Indicator 1 :
Severity of Illness (SOI) 1 Discharge Home cases
Element : Health (Clinical Outcome)
This KPI measures the quality level of health service delivery of
a casemix hospital/ institutions. This can be seen in the ratio of
the number of SOI 1 Death cases in every 1,000 SOI 1 home
Rationale
: discharge cases, treated in KKM hospitals/ institutions.

This also reflects the quality of data (casemix) and quality of

care.
Generally, there are three classifications of severity of illness
(Severity of Illness; SOI) that are treated in KKM hospitals/
institutions.

The severity of the disease is as follows:

a) Severity of Disease 1 (SOI 1): without comorbidities and/ or
complications,
b) Severity of Disease 2 (SOI 2): with comorbidities and/or
complications,
c) Severity of Disease 3 (SOI 3): with comorbid and/ or major
complications.
Definition of
:
Terms This degree of severity reflects the severity of the disease and
the complexity of the treatment provided. The severity of the
disease based on three main components which are:

a) other diagnosis (comorbid and complications),

b) treatment procedures given, and
c) Length of stay in ICU

The disease group with SOI 1 typically describes patients who

have no complications and comorbidities and receive
uncomplicated treatment. Cases like this should not result in
death.
Inclusion:
1. Inpatient services.
2. Patient discharge data between 1st January – 30th
Criteria : September of the assessed year.

Exclusion:
Not applicable
Numerator : Total no. SOI 1 death (in-patient)
Denominator : Total no. of SOI 1 discharged home

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Numerator x 1000
Formula :
Denominator
Standard : ≤10 death cases per 1000 patient discharged home (SOI 1)
1. Where: Data will be collected in the respective department
that caters the above inclusion criteria..
2. Who: Data collection will be carried out by the Officer,
Paramedic, or Nurse in-charge designated as the Indicator
Coordinator.
3. How to collect: Data will be extracted from the Casemix
Data collection :
application system.
4. How frequent: PVF form must be submitted every six months
to the Quality Unit of the hospital or institution.
5. Who should verify:
PVF form must be verified by Head of Department, Head of
Quality Unit and Hospital/ Institution Director. .
1. This is a yearly indicator. If the indicator is SIQ for Jan-Jun,
the SIQ form does not need to be filled.
2. Data is extracted from casemix application system on 1st
week of January of the following year to evaluate the
performance for January -September of the assessed year
Remarks : by taking into account the backlog data load of the last 3
months.
3. Reports for January to June can be extracted by the
respective hospital or institution.
4. The annual report (January to September) must use data
extracted by IPKKM

5 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Indicator 2 : # Index of unplanned readmission

Element : Health (Clinical Outcome)

Unplanned readmission is often considered to be the result of
Rationale
: suboptimal care in the previous admission leading to
readmission.
Unplanned readmission: It includes the following criteria:
• Patient being readmitted for the management of the same
clinical condition (main diagnosis) he or she was discharged.
• Readmission was not scheduled.
• Readmission to the same hospital.
• This does not include readmission requested by next-of-kin
or another department.(Applicable for General Medicine and
Paediatric readmission only.)
• This does not include patients were readmitted for different
reason but have the same underlying conditions (‘other
diagnosis’).
Definition of :
Terms Same condition: Same diagnosis as refer to the ICD 11.

Index of unplanned readmission will be assessed based on 3

indicators:
1. Percentage of medical patients with unplanned
readmission to medical ward within (≤) 48 hours of discharge.
2. Percentage of paediatric patients with unplanned
readmission to paediatric ward within (≤) 48 hours of discharge.
3. Percentage of patient readmitted to psychiatric ward
within 3 months of last discharge.
● Please refer and follow the technical specification of each of
the indicators above.
Inclusion:
1. Performance of all indicators as above.
Criteria :
Exclusion:
Not applicable
Numerator : Total index for each indicator
Denominator : Total no of indicators applicable to the hospital/ institute
Index of unplanned readmission:
Total of index for each indicator
Formula : Total no. of indicator applicable
SUMS OF INDEX 1,2,3
Examples calculation of index 1:

6 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Standard of indicator 1≤ 0.5%

Performance of indicator 1: 0.2 %
= 100-0.2
100-0.5
= 99.8
99.5
Index = 1.003

Examples calculation of index 2:

Standard of indicator 2 ≤ 0.5%
Performance of indicator 2 :0.1%
= 100-0.1
100-0.5
= 99.9
99.5
Index = 1.004

Examples calculation of index 3:

Standard of indicator 3 ≤ 25%
Performance of indicator 3: 40%
100-40
100-25
= 60
75
Index = 0.800

Calculation for index of unplanned readmission:

Index 1+ Index 2 + Index 3
3
=1.003+1.004+0.800
3
= 0.936
Standard : ≥1
1. Where: Data will be collected in the respective
department/ward that caters the above condition.
2. Who: Data will be collected by the Officer/ Paramedic/Nurse
in-charge (Indicator Coordinator) of the department/unit
3. How to collect: Data is suggested to be collected from the
Data collection : record or log book/ patient’s file.
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
1. PVF for each sub-indicator needs to be prepared and
Remarks :
reported by the respective departments.

7 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

2. Each sub-indicator's PVF needs to be compiled by appointed

personnel to generate the overall hospital performance.
3. SIQs for each sub-indicator need to be completed by the
respective departments.
4. The overall hospital performance SIQ will only need to use
the SIQs from respective departments.

Additional notes: Technical specifications are based on Clinical Service Quality Indicators (CliSQi) and KPI Hospital
Director (Institute of Psychiatric)
Discipline : General Medicine
Indicator : % of medical patients with unplanned readmission to medical ward
within (≤) 48 hours of discharge
Dimension of Quality : Effectiveness
Rationale : Unplanned readmission is often considered to be the result of suboptimal care in the
previous admission leading to readmission.
Definition of Terms : Unplanned readmission: Patient being readmitted for the management of the same clinical
condition (main diagnosis) he or she was discharged, the admission was not scheduled
and it is readmission to the same hospital. This does not include readmission requested by
next-of-kin or other department.

Same clinical condition: Same diagnosis as refer to the ICD 11.

Criteria : Inclusion:
1. All medical inpatient discharges from medical wards.
2. All subspecialty patients discharged from medical ward within the same general
medicine department (Includes CCU, CRW, nephrology wards etc.).

Exclusion:
1. Patients of < 12 years of age.
2. AOR (at own risk) discharged patients during the first admission.
3. Patients that were discharged from wards under different department.

Type of indicator : Rate-based outcome indicator

Numerator : Number of medical patients with unplanned readmissions to medical department
within (≤) 48 hours of discharge
Denominator : Total number of medical patients discharged during the same period of time the
numerator data was collected
Formula : Numerator x 100 %
Denominator
Standard : ≤ 0.5%
Data Collection : 1. Where: Data will be collected in pre-determined specified medical wards that
& cater for the above condition/ record office.
Verification 2. Who: Data will be collected by Officer/ Paramedic/ Nurse in-charge of the
department/ unit.
3. How to collect: For numerator, data is suggested to be collected on the day of
readmission. For denominator, data is from admission & discharge record book/
Hospital Information System (HIS)
4. How frequent: PVF to be sent 6 monthly to Quality Unit of hospital.
5. Who should verify: PVF must be verified by Head of Department, Head of Quality
Unit and Hospital Director.

Remarks :

8 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025
Discipline : Paediatric
Indicator : % of paediatric patients with unplanned readmission to Paediatric
Ward within (≤) 48 hours of discharge
Dimension of Quality : Effectiveness
Rationale : Unplanned readmission is often considered to be the result of suboptimal care in
the previous admission leading to readmission.
Definition of Terms : Unplanned readmission: It includes the following criteria:
● Patient being readmitted for the management of the same clinical
condition (main diagnosis) he or she was discharged.
● Readmission was not scheduled.
● Readmission to the same hospital.
● This does not include readmission requested by next-of-kin or other
department.
● This does not include patients were readmitted for different reason but
have the same underlying conditions (‘other diagnosis’).

Same clinical condition: Same diagnosis as refer to the ICD 11.

Criteria : Inclusion:
1. All paediatric inpatient discharges from Paediatric Ward.

Exclusion:
1. Neonates of ≤28 days of life.

Type of indicator : Rate-based outcome indicator

Numerator : Number of patients with unplanned readmissions to Paediatric Ward within (≤)
48 hours of discharge
Denominator : Total number of paediatric patients discharged during the same period of time
the numerator data was collected
Formula : Numerator x 100
Denominator
Standard : ≤ 0.5%
Data Collection & : 1. Where: Data will be collected in Paediatric Ward.
Verification
2. Who: Data will be collected by Officer/ Paramedic/ Nurse in-charge of the
department/ unit.
3. How to collect: For numerator, data is suggested to be collected on the day
of readmission. For denominator, data is from admission & discharge record
book/ Hospital Information System (HIS).
4. How frequent: PVF to be sent 6 monthly to Quality Unit of hospital.
5. Who should verify: PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.

Remarks : *This indicator is also being monitored as an Outcome Based Budgeting (OBB)
indicator.

9 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Discipline : Psychiatry

Indicator : % of patient readmitted to psychiatric ward within 3 months of last discharge

The quality of psychiatric care is among all reflected by readmissions to psychiatric

ward. This KPI had been implemented before with the target looking at readmission
Rationale to psychiatric ward within 1 month after discharge. It had been achieved and later
:
dropped. With the improvement of services provided, the duration of patients staying
well in the community should also increase accordingly. Patients receiving good
quality psychiatric care should not be readmitted within 3 months.
Percentage of psychiatric patients readmitted to the psychiatric ward within three
months after the last discharged.

Within 3 months: ≤3 months

Readmission: The same patient readmitted in the same unit/ hospital ≤3 months of
latest discharge.

Definition of Terms : Admission: Admitted to psychiatric ward regardless of length of stay with psychiatric
diagnoses.

Discharge: Patient’s name has been removed from ward/ hospital register

To determine whether a patient currently admitted qualifies to be included, count

backwards for the 3 calendar months from the date of current admission (e.g.
16.12.2022 look backward until 15.9.2022).
Inclusion:
1. All involuntary admissions to psychiatric ward.

Exclusion:
Criteria : 1. Voluntary admissions
2. Elective admission e.g. admission for maintenance ECT or CT-brain
3. Patients who are on home-leaves
4. Patients admitted to forensic ward.
5. Readmission after discharged from non-psychiatric ward.
Type of indicator : Rate-based outcome indicator
Numerator : Number of patients for the month readmitted within 3 months of last discharge
Denominator : Total number of patients admitted in the same month
Numerator x 100%
Formula :
Denominator
Standard : ≤25%
1. Where: Data will be collected in wards that cater for the above condition/ record
office.
2. Who: Data will be collected by Officer/ Paramedic/ Nurse in-charge (indicator
coordinator) of the department/ unit.
3. How to collect: Data is suggested to be collected from Record Book /
Data collection :
Registration Book/ Monitoring System.
4. How frequent: PVF to be sent 6 monthly to Quality Unit of hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of Quality Unit and Hospital
Director.
Remarks : Admission to the psychiatric ward (institution/ hospital) is according to the Mental
Health Act 2001.

10 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Indicator 3 : # Index of Patient Fall

Element : Health (Clinical Outcome)

Patient fall has the potential to cause severe harm. It can lead
to prolong hospital stay, morbidity or even mortality. Patient
fall is preventable with suitable safety measures such as safer
environment, assessment of patient’s risk and reducing the
risk, close monitoring of patient.

Based by recent data analysis E-incident Reporting in MOH

Hospitals 2022 from Patient Safety Unit, Medical Care Quality
Rationale : Section, Medical Development Division MOH, the most
reported incident was patient fall (2556 incidents- 30.1% of
all patient safety incidents) followed by medication error (1979
incidents-23.3%) and obstetric related incidents (757 incidents-
8.9%).

The most common type of incidents reported for older age

group was patient fall and it is second highest for pediatric age
group up to adult.
Fall is an unintentional descent to a lower level, which may or
may not result in injury.

For the purpose of Malaysian Patient Safety Goals (MPSG)

reporting, patient fall include witnessed and unwitnessed
incidents occurring in all inpatient and outpatient healthcare
facilities.

However, it does not include fall due to events such as

Definition of
: seizures, loss of consciousness, paralysis or cardiac arrest and
Terms
due to external forces, non-injurious developmental fall
among infant/ toddler or fall related to suicidal attempt.

Standard indicator based on Malaysian Patient Safety Goals 2.0

for Patient fall:

a) Rate Inpatient Patient Fall: ≤ 5 per 1000 patient‐days

b) Rate Outpatient Patient Fall: ≤ 5 %

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Inclusion:
1. Performance of all indicators as above.
Criteria :
Exclusion:
Not applicable
Numerator : Total index of each indicator
Denominator : 2
Index of Patient Fall:

Total of index for each indicator

2

Examples: SUMS OF INDEX 1 AND 2

Examples calculation of index 1:

Standard of indicator 1: ≤ 5 per 1000 patient-days

Performance of indicator 1: 10 per 1000 patient-days
= 100-10
100-5
= 90
95
Formula : Indeks = 0.947

Examples calculation of index 2:

Standard of indicator 2: ≤ 5 %
Performance of indicator 2: 2%
= 100-2
100-5
= 98
95
Index = 1.032

Calculation for index of patient fall:

= (Index 1+ Index 2)/2
= 0.947+1.032
2
= 0.989
Standard : ≥1
1. Where: Data will be collected in the respective
department/ward that caters the above condition.
2. Who: Data will be collected by the Officer/
Data collection : Paramedic/Nurse in-charge (Indicator Coordinator) of the
department/unit
3. How to collect: Data is suggested to be collected from the
record or log book/ patient’s file.

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

4. How frequent: PVF to be sent 6 monthly to Quality Unit of

hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
Remarks : 1. Malaysian Patient Safety Goal (MPSG) 2.0 Guideline

13 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

% Performance of Patient Safety Incident Reporting and

Learning System and Root Cause Analysis and Action Plan
Indicator 4 :
(RCA2) for Actual Patient Safety Incidents Resulting in Severe or
Death Outcome in the corresponding year
Element : Health (Quality Care)

To ensure the implementation of Patient Safety Incident

Reporting and Learning System along with proper remedial
action or risk reduction strategy, especially for Root Cause
Rationale
: Analysis carried out for incidents resulting in severe or death
outcome. This is to encourage reporting and ensure the safety
of patients in the hospital by reducing or preventing future
similar incidents.

Recommendation: Any corrective action, risk reduction strategy

and remedial measure to prevent or reduce incident. Also
known as ‘Action Plan’ in RCA report. Strength of ‘Action Plan’
is based on the ‘Action Hierarchy’ in the 2017 Guideline on
Implementation of Incident Reporting and Learning System 2.0
and is classified into strong, intermediate and weak
‘Action Plan’.

Root cause analysis (RCA2): Is a structured investigation that

aims to identify the ‘root cause’ of the problem and actions
necessary to eliminate it. It is a risk management tool to
understand WHY the problem occurs.
Definition of
:
Terms
Patient safety incident: An event or circumstance which could
have resulted, or did result, in unnecessary harm to a patient.
An incident can be a reportable circumstance, near miss,
no harm incident or harmful incident (adverse event).

Patient Outcome: The impact on a patient, whether wholly or

partially resulting from an incident. Severity, duration of harm
and treatment implication is taken into account when
determining the outcome. The classification of outcome is
based on the 2017 Guideline on Implementation of Incident
Reporting and Learning System 2.0 for Ministry of Health
Hospitals.

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Inclusion:
1. For the purpose of monitoring of the indicator, only actual
patient safety incidents which resulted in severe or death
outcome will be taken into the calculation for action taken
for RCA2 within the time frame of the cohort (date taken is
the date of incident reported).
Criteria :
2. The total number of all patient safety incidents (actual and
near miss) reported is calculated by counting all incidents
reported within the time frame of the cohort (date taken is
the date of incident reported).

Exclusion:
1. Recommendation in RCA2 report that occur during disaster.

Total no. of RCA2 report (severe

Total No. all of Patient Safety and death outcome) with at least
Incident Reported ( x )* 1 intermediate or strong action
x plan carried out ( N )
Formula : x 100
Incident Constant ( k ) Total no. of
RCA2 report (severe
and death outcome) ( D )
*Where maximum of X = K

Total No. of Total numbers of all patient safety incident (actual and near
Patient Safety miss) reported within the time frame of cohort ( X ) (date taken
:
Incident is the date of incident reported). The maximum number for
Reported (x) ( X ) is capped to the Incident constant ( K ) in the formula.
The constant is derived from the median number of all patient
Incident : safety incidents (actual and near miss) reported by hospital
Constant (k)
category for the previous year.
Total number of RCA2 report for patient safety incidents
resulting in severe and death outcome with at least 1
intermediate or strong action plan carried out* within the time
frame of cohort (date taken is the date of incident reported).
Numerator (N) : Note : The numerator is the number of RCA2 report with at least
1 strong or intermediate action plan carried out. If the RCA2
report had more than one strong or intermediate action plan
carried out for the report, it is still counted as 1.

15 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

*An action plan is considered carried out if initial action toward

its implementation is already in place, which includes a request
letter or writing of paperwork for implementation.

Total number of RCA2 report for patient safety incidents

Denominator (D) : resulting in severe and death outcome within the time frame of
cohort (date taken is the date of incident reported).
Standard : ≥ 70%
1. Where: Data will be collected in the Quality Unit
2. Who: Data will be collected by the Quality Officer/
Paramedic/ Nurse in-charge (Indicator Coordinator) of the
department/ unit.
3. How to collect: Data is collected from the Action Plan Table in
the RCA report submitted to the Quality Unit.
4. How frequent: PVF to be generated 6 monthly by the Quality
Unit of the hospital. The cohort for patient safety incident and
RCA2 report (date taken is the date of incident reported) is
according to:
Data collection :
● January - June: 1st October (previous year) to 31st March
(current year)
● July - December: 1st April (current year) to 30th
September (current year)
● January – December : Please refer to the generated
performance based on the tool for calculation (excel)
given.
5. Who should verify:
PVF must be verified by Head of Quality Unit, and Hospital
Director.

Tool for calculation (excel) is available at:

Remarks :
https://tinyurl.com/hpia-rca-23-kkm

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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Additional notes for implementation:

Note the strength of action and example of action plan in the Action Hierarchy table. The light
blue shaded area in the table indicates strong and intermediate action plans that are easier to
implement.

Action Hierarchy
Action Category Example
Stronger Architectural/physical Replace revolving doors at the main patient entrance into the building
Actions plant changes with powered sliding or swinging doors to reduce patient falls.
(these tasks
require less New devices with Perform heuristic tests of outpatient blood glucose meters and test
reliance on usability testing strips and select the most appropriate for the patient population being
humans to served.
remember to
perform the Engineering control Eliminate the use of universal adaptors and peripheral devices for
task correctly) (forcing function) medical equipment and use tubing/fittings that can only be connected
the correct way (e.g.,
IV tubing and connectors that cannot physically be connected to
sequential compression devices or SCDs).

Simplify process Remove unnecessary steps in a process.

Standardize on Standardize on the make and model of medication pumps used
equipment or throughout the institution. Use bar coding for medication
process administration.
Tangible Participate in unit patient safety evaluations and interact with staff;
involvement by 2
support the RCA process; purchase needed equipment; ensure
leadership
staffing and workload are balanced.

Intermediate Redundancy Use two RNs to independently calculate high-risk medication dosages.
Actions
Increase in Make float staff available to assist when workloads peak during the day.
staffing/decrease in
workload
Software Use computer alerts for drug-drug interactions.
enhancements,
modifications
Eliminate/reduce Provide quiet rooms for programming PCA pumps; remove distractions
distractions for nurses when programming medication pumps.

Education using Conduct patient handoffs in a simulation lab/environment, with after

simulation- based action critiques and debriefing.
training, with periodic
refresher sessions and
observations
Checklist/cognitive Use pre-induction and pre-incision checklists in operating rooms. Use a
aids checklist when reprocessing flexible fiber optic endoscopes.

Eliminate look- and Do not store look-alikes next to one another in the unit medication
sound-alikes room.

Standardized Use read-back for all critical lab values. Use read-back or repeat-back for
communication tools all verbal medication orders. Use a standardized patient handoff format.

Enhanced Highlight medication name and dose on IV bags.

documentation,
communication

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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Weaker Actions Double checks One person calculates dosage, another person reviews their
(these tasks calculation.
require more Warnings Add audible alarms or caution labels.
reliance on
humans to New procedure/ Remember to check IV sites every 2 hours.
remember to
perform the task memorandum/policy
correctly)
Training Demonstrate correct usage of hard-to-use medical equipment.
(Source: National Patient Safety Foundation. Improving Root Cause Analyses and Actions to Prevent Harm. Version 2, 2016; based on VA National Center for Patient Safety.)

18 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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# Index of paramedics who have a CURRENT trained status in

Basic Life Support (BLS) in the corresponding year
Indicator 5 :
A: acute care area
B: non acute area
Element : Health (Quality Care)
Basic Life Support is an important skill for all healthcare
personnel to have and it is an important element of the
Rationale
: Continuous Professional Development. Therefore, continuous
updating of this skill will ensure the current and latest
management of patient care is being practised.
Index of paramedics who have a CURRENT trained status in
Basic Life Support (BLS) will be assessed based on 2 indicators:

1. Acute care area: Emergency and Trauma Department, and

Intensive Care Area (ICU, CCU, OT, HDW, Labour Room,
Burn Unit, PICU, NICU, Neuro ICU and Haemodialysis Unit).
Standard in acute area: ≥ 70%
2. Non acute area: all other clinical and administrative areas
Definition of – e.g., Quality Unit, Public Health Unit, Occupational &
:
Terms Health Unit, Nursing Administrative Office.
Standard in non-acute area: ≥ 30%

CURRENT trained status: The valid period of certification is

determined by either the National Committee on Resuscitation
Training (NCORT) or the relevant State/Hospital committee.

Paramedic: Refer to the medical assistant and nurse who work

in the hospital.
Inclusion:
1. Paramedic who is currently working in the acute/ non acute
care area for more than 6 months

Exclusion:
1. Paramedic who was transferred-in to the acute/ non acute
Criteria : care area for less than 6 months.
2. Paramedic who is currently working in the acute/ non acute
care area for less than 6 months.
3. Paramedic who has been on medical leave for more than 6
months.
4. Paramedic who are not fit to perform resuscitation.
e.g., spine problem, special needs.

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Numerator : Total index of each indicator

Total no. of indicator applicable
Denominator : * If the facility does not have acute area, ONLY indicator of non
acute area is applicable.
Index of paramedics who have a CURRENT trained status in
Basic Life Support (BLS):

Total of index for each indicator

Total no. of indicator applicable

Examples: SUMS OF INDEX 1 AND 2

Examples calculation of index 1:

Standard of paramedics who have a CURRENT trained status in
Basic Life Support (BLS) in acute areas: ≥ 70%
Performance of indicator 1: 73%
Measurement of index for indicator 1:
= 73
70
Formula : Index = 1.042

Examples calculation of index 2:

Standard of paramedics who have a CURRENT trained status in
Basic Life Support (BLS) in non-acute areas: ≥ 30%
Performance of indicator 2: 28%
Measurement of index for indicator 2:
= 28
30
Index = 0.9333

Calculation for index of paramedics who have a CURRENT

trained status in Basic Life Support (BLS):
= (Index 1+ Index 2)/2
= 1.042 + 0.9333
2
= 0.988
A: Acute area ≥ 70%
B: Non-Acute area ≥ 30%
Standard :
Index: ≥ 0.9
1. Where: Data will be collected in the respective department/
ward that caters the above condition.
Data collection :
2. Who: Data will be collected by the Officer/ Paramedic/ Nurse
in-charge (Indicator Coordinator) of the department/ unit

20 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
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3. How to collect: Data will be collected from the record book

from each unit/ department/ ward.
4. How frequent: PVF to be sent 6 monthly to the Quality Unit
of the hospital
5. Who should verify:
PVF must be verified by Head of Quality Unit, and Hospital
Director.
1. This is a yearly indicator. If the indicator is SIQ for Jan-Jun,
SIQ form does not need to be filled.
2. Reporting for the period from January to June will use the
Remarks :
cumulative data as of June.
3. Reporting for the period from January to December will use
the cumulative data as of December.

21 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
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% of fire drill that has been carried out by the hospital in the
Indicator 6 :
corresponding year
Element : Health (Quality Care)
Fire drills are essential in any workplace or public building for
practicing what to do in the event of a fire.
Rationale Not only do they ensure that all staff, customers, and visitors in
:
the premises understand what they need to do in case of fire,
but they also help to test how effective the fire evacuation plan
is and to improve certain aspects of the fire provisions.
Definition of Fire Drill: A practice of the emergency procedures to be used in
:
Terms case of fire with the involvement of Fire & Rescue Department.
Inclusion:
1. All fire drills that have been planned in the corresponding
year
Criteria :
Exclusion:
Not applicable
Number of fire drill that has been carried out according to the
Numerator :
plan in the corresponding year
Denominator : 1
Formula : Numerator x 100%
Denominator
Standard : 100%
1. Where: Data will be collected in the respective department/
ward that caters the above condition.
2. Who: Data will be collected by the Officer/
Paramedic/Nurse in-charge (Indicator Coordinator) of the
department/unit
3. How to collect: Data will be collected from the record book/
Data collection : registration book from each unit/ department/ ward or any
form of documentation.
4. How frequent: PVF to be sent 6 monthly to the Quality Unit
of the hospital
5. Who should verify:
PVF must be verified by Head of Quality Unit, and Hospital
Director.
1. This is a yearly indicator. If the indicator is SIQ for Jan-Jun,
SIQ form does not need to be filled.
Remarks : 2. Any SIQ due to cancellation and/or postponement from
Fire & Rescue Department will NOT be included in Hospital
Report Card measurement.

22 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

% of clinical department conducting clinical audit in the

Indicator 7 :
hospital/institution in the corresponding year
Element : Health (Quality Care)
Clinical audit is at the heart of clinical governance. It offers the
mechanisms for reviewing the quality of care provided to
Rationale patients.
:
It addresses quality issues systematically and explicitly,
providing reliable information and highlight the need for
improvement.
Clinical audit is a quality improvement process that seeks to
improve patient care and outcomes through systematic review
of care against explicit criteria and the implementation of
change.
Definition of Where indicated, changes are implemented and further
:
Terms monitoring is used to confirm improvements in healthcare
delivery. (Source: National Institute for Clinical Excellence 2002)

Completed 1st cycle means that the clinical audit is finished and
the re-audit is being planned
Inclusion:
1. All CLINICAL departments.
2. Clinical audit conducted in the corresponding year or 1 year
Criteria : prior and completed 1st cycle in the corresponding year.

Exclusion:
1. New service that was established in less than 12 months.
Number of clinical departments that conducted at least one
Numerator :
clinical audit in the corresponding year
Denominator : Total number of clinical departments in the hospital/ institution
Formula : Numerator x 100%
Denominator
Standard : ≥ 30%
1. Where: Data will be collected in the respective department/
ward that caters the above condition.
2. Who: Data will be collected by the Officer/
Paramedic/ Nurse in-charge (Indicator Coordinator) of the
department/ unit
Data collection :
3. How to collect: Data is suggested to be collected from the
record or log book/ patient’s file/ etc
4. How frequent: PVF to be sent 6 monthly to the Quality Unit
of the hospital
5. Who should verify:

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PVF must be verified by Head of Quality Unit, and Hospital

Director.
1. Clinical department for non-specialist hospital refers to
Emergency & Trauma Department, Obstetrics &
Gynaecology Ward, Paediatric Ward, Female Ward and
Male Ward. (Total of 5 Departments for non-specialist
hospital)
2. Clinical department for specialist hospital refers to all
Remarks : hospital that has resident specialist.
3. A subspecialty that has its own appointed Head of
Department (HOD) is considered a clinical department and
needs to conduct its own clinical audit.
4. Refer to Clinic Audit Guideline 2023.
5. This is a yearly indicator. If the indicator is SIQ for Jan-Jun,
SIQ form does not need to be filled.

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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Indicator 8 : % of Hospitals Achieving the Specified Bed Waiting Time

Element : Responsiveness
This KPI refers to the performance of each Ministry of Health
(MOH) hospital in ensuring that non-critical patients from the
Emergency Department, who have been decided for admission
to regular wards (non-critical beds), are admitted within the
stipulated time frame. This KPI is implemented in all MOH
hospitals with an Emergency Department.

Bed Waiting Time (BWT): Measures the time between the

decision for admission to a ward in the Emergency Department
(ED) and the patient's admission to a bed in the ward.

This KPI serves as an indicator to monitor the effectiveness of

patient bed management in each hospital, and it falls under the
jurisdiction of the Hospital Director.
Rationale
:
Prolonged waiting time is a source of patient dissatisfaction in
health care. In patient flow there are few indicators related to
timely and efficient transitions in care. One of it is bed waiting
time. Prolonged bed waiting time is one of the key factors
contributing to emergency department (ED) overcrowding.
Prolonged stay in Emergency Department also associated with
higher inpatient mortality rates and longer hospital length of
stay. Prolonged bed waiting time is also one of the result from
inefficient discharge process. Managing demand for admission
at ED to inpatients’ wards is one of the important aspects in
Hospital Operation Management. Efforts to reduce may
improve outcomes for ED patients who are admitted to the
hospital. Every hospital must look into continuously improving
it.
Bed Waiting Time (BWT): The average waiting time for a bed
from the doctor's order for admission to a regular ward until the
patient is transferred to the bed.
Definition of
: Regular/Non-Critical Ward: Wards other than critical
Terms
wards/areas/rooms such as ICU, CCU, PICU, NICU, HDW, SCN,
Burn Unit, including acute beds in regular wards. The beds
involved are sub-acute beds and regular beds in non-critical
wards.

25 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Critical Patients: Patients requiring specialized observation who

need to be placed in critical wards/rooms/areas.
Inclusion:
1. Hospitals with Emergency and Trauma Department
services.
2. Involves patients who receive treatment in the Emergency
Department and are confirmed for admission to non-critical
wards.
3. Non-critical patients who are suitable to be placed in sub-
acute beds and regular beds in non-critical wards.

Exclusion:
1. Critically ill patients who should be placed in a critical
ward/acute beds but are instead placed in sub-
Criteria : acute/regular beds in a non-critical ward (due to the
unavailability of beds in the critical ward).
2. Referral cases for admission (step-up/step-down).
3. Patients requiring isolation (e.g., infectious disease patients)
or close monitoring (e.g., mental health patients).
4. Isolation ward space that is permanent, temporary, or
transit.
5. Patients who need to undergo procedures while being
transferred to the ward (e.g., X-ray).
6. Patients who need to be sent directly to the operating
theatre for any procedure.
7. Covid-19, SARI, ILI, PUI patients, and patients requiring a PCR
test in the Emergency Department (before ward admission).
Numerator : The total time for all patients (samples) recorded in one week.
Denominator : The number of patients (samples) recorded in one week
Numerator
Denominator

Example Calculation:
Patient Admission Patient Arrival at Bed Waiting
(A) Decision by Assigned Ward Time (in
Doctor in Bed minutes) (B)
Formula :
Emergency
Department
Ali 11:00 AM 11:45 AM 45

Mei Mei 11:10 AM 12:30 PM 80

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Chandran 11:33 AM 12:12 PM 39

Average Weekly BWT= Total (B) / Total (A)

Total (B)=45+80+39=164minutes
Total (A)=3 patients

Average Weekly BWT =164 / 3 = 54.67 minutes

i) The average weekly BWT is ≤ 360 minutes for hospitals with
an official annual Bed Occupancy Rate (BOR) (from the
previous year) of ≥ 85%.
Standard :
ii) The average weekly BWT is ≤ 240 minutes for hospitals with
an official annual Bed Occupancy Rate (BOR) (from the
previous year) of < 85%.
1. Where: Data will be collected in the Emergency & Trauma
Department.
2. Who: Data will be collected by the Officer/
Paramedic/Nurse in-charge (Indicator Coordinator) of the
department/unit
3. How to collect: Data is suggested to be collected from the
record or log book/ patient’s file. Data to be collected twice
Data collection :
a year for period of one week each with minimum sample
size of 200 or universal sampling.
4. How frequent: PVF to be sent 6 monthly to the Quality Unit
of the hospital
5. Who should verify:
PVF must be verified by Head of Quality Unit, and Hospital
Director.
1. Reporting for the period of January – December will use
the performance of July – December of the current year.
2. Data collection must be conducted twice a year for a one-
week period during the early and late phases of the year
(Monday to Sunday).
3. The dates for data collection will be determined by the
Remarks :
respective State Health Departments. The sample size is
200 cases or the total number of all cases throughout the
one-week data collection period.
4. The data involves patient admissions to Medical, Surgical,
Orthopedic, Pediatric, and Gynecology wards, or relevant
female, male, and pediatric wards.

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% of patients with waiting time of ≤ 90 minutes to see doctor

Indicator 9 :
at the Specialist Clinic
Element : Responsiveness
1. MOH aims for waiting time for consultation at clinic to be less
than 90 minutes, in line with patient-centered services.
Waiting time is the time patient first registers in the hospital
till the time patient is seen by doctor.
2. The waiting time is based on patient’s experience from the
Rationale time the patient first registers at the first counter in the
:
hospital till seen by doctor.
3. For hospitals to eliminate or reduce waiting time, it is
important to balance between the demand for
appointments and the supply of appointments. One needs
to identify opportunities for improvement by strengthening
the policy of outpatient services in hospital.
Definition of Waiting time: Time of registration or time of appointment
:
Terms given to patient (whichever is later) till the doctor consultation.
Inclusion:
1. Patient coming for the purpose of doctor’s consultation.
2. The first clinic consultation for patient with multidisciplinary
clinic appointment.
3. Visiting clinic in non-specialist hospital.

Criteria : Exclusion:
1. Patients come without an appointment (“walk-in” patients).
2. Patients that need to do procedures in another department
on the same day before seeing the doctors (e.g., blood
taking or imaging).
3. Patient come to Opthalmology Specialist Clinic, Orthopaedic
Specialist Clinic and Geriatric Specialist Clinic
Number of patients with waiting time of ≤ 90 minutes for to see
Numerator :
doctor at the Specialist Clinic
Denominator : Total number of patients at the Specialist Clinic
Formula : Numerator x 100%
Denominator
Standard : ≥ 90%
1. Where: Data will be collected in the respective
department/ward.
Data collection : 2. Who: Data will be collected by the Officer/
Paramedic/Nurse in-charge (Indicator Coordinator) of the
department/unit.

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3. How to collect: Data is suggested to be collected from the

record or log book/ patient’s file/ waiting slip. Data will be
collected for a whole week (5 Working Days: Monday –
Friday or Sunday – Thursday) and will be done 4 times per
year (Quarterly).
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital. Quality Unit will compile the performance data of
all Specialist Clinics to generate hospital performance.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
1. Outpatients Department (OPD) will be included only IF the
Hospital does not have any visiting specialist clinic and OPD
is operated by the Hospital.
2. PVF for each sub-indicator needs to be prepared and
reported by the respective departments.
Remarks : 3. Each sub-indicator's PVF needs to be compiled by appointed
personnel to generate the overall hospital performance.
4. SIQs for each sub-indicator need to be completed by the
respective departments.
5. The overall hospital performance SIQ will only need to use
the SIQs from respective departments.

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% of workplace inspection performed quarterly

Indicator 10 :
in the corresponding year
Element : Responsiveness
Rationale To ensure safety of the patient and healthcare workers
:
involved.
Workplace: Refers to any premises or part thereof where work
is conducted. In a hospital setting, this includes specific units or
departments, each considered a distinct workplace due to its
unique tasks, risks, and work procedures. Examples include the
Emergency Department, Intensive Care Unit, Surgery
Department, laboratories, operating theaters, and
Definition of
: administrative offices.
Terms
Workplace Inspection: An audit that is conducted by the
hospital’s Safety and Health Committee (JKKK) / OSH unit.

Audit finding: Any finding in the KKP(BKP)/PTK-01 Form that

can be used for the purpose of monitoring and improvement.
Inclusion:
Not applicable
Criteria :
Exclusion:
1. Areas under construction.
Numerator : Number of workplace inspection performed quarterly
At least 3 workplaces had been inspected quarterly
Denominator :
(Total= 12 workplace inspection/ year)
Quaterly Performance

Numerator x 100%
Denominator (3)
Formula :
Yearly Performance

Numerator x 100%
Denominator (12)

Standard : 100%
1. Where: Data will be collected from the hospital’s Safety and
Health Committee (JKKK) / OSH unit/ departments
Data collection : 2. Who: Data will be collected by the hospital’s Safety and
Health Committee (JKKK) / Person in charge of safety (Safety
Officer).

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3. How to collect: Data will be collected from the record book/

audit finding report/ minutes regarding safety/ monitoring
system by the hospital’s Safety and Health Committee
(JKKK).
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Quality Unit, and Hospital
Director.
1. Based on the requirements in Occupational Safety and
Health Act 1994 (Act 514), Safety and Health Committee
must be established in the hospital.
2. Workplace inspections need to be conducted in the hospital
by Safety and Health Committee or any person appointed.
3. KKP(BKP)/PTK-01 Form is used for the purpose of workplace
inspection in the hospital and other healthcare facilities
under MOH.
4. All the findings identified and documented during the
assessment/ audit, should be presented and discussed in the
Safety and Health Committee Meeting, chaired by the
Hospital Director.
Remarks : 5. Control measures to improve the workplace inspection
finding and effectiveness of the control measures also can
be discussed during the meeting.
6. The head of the OSH Unit needs to make sure that the
Workplace Inspection Report of the corresponding year is
sent to the State KPAS officer.
7. The head of the OSH Unit needs to make sure that the HPIA
report is sent to Penyelaras OSH, Bahagian Perubatan, JKN.
8. The Penyelaras OSH, Bahagian Perubatan, JKN needs to
compile the Work Place Inspection State Report to the
Occupational Safety and Health Unit, Medical Development
Division by 14 January of the next year for the
corresponding year.

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% of hospital or medical institutional staff undergo health

Indicator 11 :
screening for risk of Non-Communicable Disease (NCD)
Element : Responsiveness
National Health Screening Initiative (NHSI) is one of the
initiatives under the 3rd Pillar of Agenda Nasional Malaysia
Rationale Sihat (ANMS) which is Kawalan Kesihatan Kendiri.
:
Health screening allow early detection of NCD, offering early
treatment and ensure productivity among staff.
Health screening: Test/ screening/ assessment to detect early
symptoms of chronic disease, facilitating prevention and
treatment of disease.
Compulsory test/ screening :
I. Body Mass Index (BMI).
II. Waist circumference
III. Random Blood Sugar (RBS) or Fasting Blood Sugar (FBS).
IV. Blood Cholesterol
V. Blood Pressure Measurement
VI. Smoking status
VII. Mental health screening

Definition of
: Frequency of screening : Once a year
Terms
Risk of Non-Communicable Disease (NCD): The main risk factor
of NCD is unhealthy lifestyle such as unhealthy eating,
inactivity, smoking, alcohol consumption and unhealthy stress.

Non-Communicable Disease (NCD): NCD include hypertension,

diabetic, heart disease and hyperlipidaemia

Staff : Public servant working in hospital or medical institution

under Ministry of Health (MOH)

Eligible staff : Staff with unknown NCD and non-pregnant staff

Under Treatment: Currently under follow up in hospital or clinic

Inclusion:
1. Staff who is eligible for screening and working in hospital or
medical institution as of 1st January of current year.
Criteria :
Exclusion:
1. Staff who has established NCD such as hypertension,
diabetic, heart disease and hyperlipidaemia

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2. Pregnant staff
3. Concession company staff.
Number of staff working in hospital or medical institution as of
Numerator :
1st January of current year who has undergo screening.
Number of staff who are eligible for screening and working in
Denominator :
hospital or medical institution as of 1st January of current year.
Formula : Numerator x 100%
Denominator
Standard : ≥ 70%
1. Where: Data will be collected from the OSH unit/ respective
department.
2. Who: Data will be collected by the Officer/
Paramedic/Nurse in-charge (Indicator Coordinator) of the
department/unit.
3. How to collect: Data is suggested to be collected from record
Data collection :
or log book either physically or online.
4. How frequent: PVF to be sent 6 monthly to the Quality Unit
of the hospital.
5. Who should verify:
PVF must be verified by Head of Quality Unit, and Hospital
Director.
1. This is yearly indicator. If the indicator is SIQ for Jan-Jun, SIQ
Remarks :
form does not need to be filled.

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Indicator 12 : % of bills payment within 14 days

Element : Fair Financing & Governance

This refers to the percentage of bill payments settled within 14
days in accordance with Treasury Instruction (AP) 103(a). The
Department Head must ensure that all bills are paid promptly
within 14 days from the date of receipt, in a complete and
Rationale
: accurate manner.

More effective monitoring can be implemented at the

department level to ensure that all payments are made
promptly for better future financial planning.
Within 14 days: Time from all completed documents received
until payment
Definition of
:
Terms
Bills: Complete documentation of all bills submitted to the
financial department.
Inclusion:
1. All bills received by the financial department
Criteria :
Exclusion:
Not applicable
Numerator : All bills paid by the financial department within 14 days
Denominator : All bills received by the financial department
Formula : Numerator x 100%
Denominator
Standard : ≥99%
1. Where: Data will be collected in the administrative
unit/financial unit
2. Who: Data will be collected by the Officer unit in-charge
3. How to collect: Data will be collected from from the
registration book or computerized record system
Data collection :
4. How frequent: PVF to be sent 6 monthly to the Quality Unit
of the hospital
5. Who should verify:
PVF must be verified by Penolong Pegawai Tadbir / Deputy
Director (Administration), and Hospital Director.
Remarks : 1. Surat Pekeliling KSU KKM Bil.11 Tahun 2019

34 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Indicator 13 : % of assets in the hospital that were registered within 2 weeks

Element : Fair Financing & Governance

To assure the assets attained are safe for usage and is
Rationale acceptable for maintenance by concession company (ie cost
:
effectiveness of assets management and applied patient safety
criteria)
Assets: Hospital properties that were received in the current
year.
Definition of
:
Terms
Registered within 2 weeks: Upon completing and passing the
process of testing and commissioning.
Inclusion:
Assets that must be registered are:
1. Asset received through purchase/hire purchase with
government funds
Criteria : 2. Asset received as gifts or transfers
3. Asset through legal processes or agreements

Exclusion:
Not applicable
Numerator : Number of assets that were registered within 2 weeks
Denominator : Total number of assets that were received in the current year
Formula : Numerator x 100%
Denominator
Standard : 100%
1. Where: Data will be collected from the administration unit/
departments.
2. Who: Data will be collected by the Officer/ staff of the
Administration unit in-charge for assets and inventory.
3. How to collect: Data will be collected from the record book/
registration book/ monitoring system in the administrative
Data collection :
unit/ department.
4. How frequent: PVF to be sent 6 monthly to the Quality Unit
of the hospital
5. Who should verify:
PVF must be verified by Penolong Pegawai Tadbir / Deputy
Director (Administration) and Hospital Director.
1. Pekeliling Perbendaharaan - Tatacara Pengurusan Aset Alih
Remarks :
Kerajaan

35 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

% of new hospital staffs who attended the Orientation

Indicator 14 : Programme within 3 months of their placement at the Unit or
Department in the hospital
Element : Fair Financing & Governance
Orientation Programme is a platform used to provide
information in regards to the institution/ hospital to the
Rationale newcomers (i.e. staffs). This Orientation Program will assist the
:
new staffs to be familiarized with the institution/ hospital,
hence, indirectly it will boost their productivity and their self
confidence in the new environment.
New staffs: Newly reported personnel (transferred in/ newly
appointed/ new placement) to the hospital/ institution.

Orientation Program: Program organized/ conducted by the

Definition of
: Hospital/ Institution comprises of introduction of the system,
Terms
work process and environment.

3 months: Period begins from the date of reporting or the date

of postponement, whichever is later.
Inclusion:
1. Orientation Programme that was conducted by the Hospital/
Institution

Criteria : Exclusion:
1. Staffs whom transferred out/resigned from the hospital ≤ 3
months after reporting for duty.
2. Staffs who underwent training outside <1 year for training
purpose

Number of new staffs who attended the Orientation Program

Numerator :
within 3 months of their placement in the hospital
Denominator : Total number of new staff reported to the hospital.
Formula : Numerator x 100%
Denominator
Standard : 100%
1.Where: Data will be collected in every unit/ department/
wards.
2. Who: Data will be collected by the Officer/ staff in-charge for
Data collection :
the Orientation Program in each department/ unit/ ward
(Administrative unit/ department responsible for the overall
data collection)

36 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

3. How to collect: Data will be collected from the record book/

human resource record.
4. How frequent: PVF to be sent 6 monthly to the Quality Unit
of the hospital
5. Who should verify:
PVF must be verified by Head of Department/Unit, Head of
Quality Unit, and Hospital Director.
1. Staff who reported after 31st March or after 30th September
of the current year will be carried to the next term/ year of the
denominator which means;
● 1st Term Evaluation: For staffs who reported duty on 1st
Remarks : October of the previous year to the 31st March of the
current year.
● 2nd Term Evaluation: For staffs who reported duty on 1st
April of the current year to the 30th September of the
current year.

37 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

SATELLITE INDICATORS

SATELLITE INDICATORS
*** Satellite indicators encompass indicators from State Health Directors KPIs or any top
management’s KPIs that need to be monitored by the hospital director. It is important to note
that these indicators will be changed annually. Kindly refer to the respective technical
specifications for each KPI.

INDICATORS STANDARDS

State Health Director KPI 2025

4. # Purata Performance Indeks Jangkitan Aliran Darah
berkaitan Penjagaan Kesihatan (bacteraemia) ≥ 1.00
(State Health Director KPI 2025)
5. % Bayi Baru Lahir yang Menjalani Saringan Pendengaran
(Universal Newborn Hearing Screening) dalam Tempoh 28
Hari Selepas Kelahiran di Hospital/ Fasiliti Kesihatan ≥85 %
Kerajaan
(State Health Director KPI 2025)
6. % Peralatan Perubatan/ Sistem Kejuruteraan Fasiliti
Mencapai Uptime di Bawah Perkhidmatan Sokongan
≥95 %
Hospital (PSH)
(State Health Director KPI 2025)

Deputy State Health Director (Medical) KPI 2025

1. # Indeks Pencapaian Petunjuk Prestasi Utama (KPI) Kualiti
Perkhidmatan Perubatan Klinikal ≥ 0.9
(Deputy State Health Director (Medical) KPI 2025)
2. # Purata Performance Indeks Jangkitan Aliran Darah
berkaitan Penjagaan Kesihatan (bacteraemia) ≥1
(Deputy State Health Director (Medical) KPI 2025)
3. % Bayi Baru Lahir yang Menjalani Saringan Pendengaran
(Universal Newborn Hearing Screening) dalam Tempoh 28
Hari Selepas Kelahiran di Hospital/ Fasiliti Kesihatan ≥ 85%
Kerajaan
(Deputy State Health Director (Medical) KPI 2025)
4. % Hospital yang Mencapai Bed Waiting Time yang
Ditetapkan ≥ 80%
(Deputy State Health Director (Medical) KPI 2025)

38 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

5. % Keputusan Lembaga Perubatan Selesai Bersidang dalam

Tempoh Masa yang Ditetapkan ≥75%
(Deputy State Health Director (Medical) KPI 2025)
6. % Jururawat yang Bertugas di Penempatan Klinikal > 6
Bulan Diperakui Lulus dan Mendapat Privilege ≥ 80%
(Deputy State Health Director (Medical) KPI 2025)

39 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

HOSPITAL REPORT CARD

HOSPITAL REPORT CARD

CONTENTS PAGE
1. Weighted Percentile – Point – Scoring Concept (PPS-C)
42
2. Cluster Hospital Performance
44
3. Casemix Performance
45
4. Patient Satisfaction Questionnaire -18 (PSQ – 18)
47

40 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Weighted Percentile – Point – Scoring Concept (PPS-C)

The hospital report card system by the Ministry of Health Malaysia uses a weighted
Percentile – Point – Scoring Concept (PPS-C) to assess hospital performance
comprehensively. Here is a detailed breakdown of the process:

Scoring Components and Weightage

1. HPIA Index (50%)
2. Casemix Performance (10%)
3. Cluster Performance (25%)
4. Patient Satisfaction Questionnaire-18 (PSQ-18) (15%)

Step-by-Step Calculation
1. HPIA Index
⮚ Step 1: Calculate the HPIA index based on specific indicators.
⮚ Step 2: Analyze hospital performance based on hospital types using the percentile
method to ensure fair comparison.
⮚ Step 3: Generate a score on a scale of 1 to 5 based on the percentiles.
❖ E.g., Percentile ranges may correspond to scores as follows:
▪ 90th percentile or higher = 5
▪ 75th-89th percentile = 4
▪ 50th-74th percentile = 3
▪ 25th-49th percentile = 2
▪ Below 25th percentile = 1

• Step 4: Apply the weightage (50%) to the generated score.

2. Casemix Performance
• Repeat Steps 1–4 for Casemix Performance, applying a weightage of 10%.

3. Cluster Performance
• Repeat Steps 1–4 for Cluster Performance, applying a weightage of 25%.

4. PSQ-18
• Repeat Steps 1–4 for PSQ-18, applying a weightage of 15%.

5. Total Scoring and Ranking

41 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

• Add up the weighted scores from all four elements to derive the total score for
each hospital.
• Rank the hospitals using centiles to determine overall performance.
• Assign star ratings:
o 4-star and 5-star hospitals are those that score in the top centiles based
on the ranking.
This method ensures that hospital performance is evaluated systematically and fairly,
accounting for diverse factors like hospital type, service complexity, and patient
satisfaction.

42 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Cluster Hospital Performance

SEKSYEN PERKARA TATACARA SKOR PERATUS(%)

Pengurusan Organisasi Kluster di
A Tadbir Urus 7 20
JKN dan Kluster

Pentadbiran Kluster merangkumi

LNPT, pengurusan waran secara
B Pengurusan 7 20
kluster dan pengurusan
perolehan secara kluster

Status Perkhidmatan ETD;

Perkhidmatan dijalankan secara lawatan pakar/
Kecemasan & koordinasi atau bersepadu dan 4 10
Trauma membentuk jabatan yang
diketuai oleh Ketua Jabatan

Perkhidmatan Internal Medicine

Perkhidmatan dijalankan secara lawatan pakar/
Perubatan Dalam koordinasi atau bersepadu dan 4 10
C (Internal Medicine) membentuk jabatan yang
diketuai oleh Ketua Jabatan

Perkhidmatan lain- Tiga (03) perkhidmatan terbaik

12 10
lain; 3 terbaik yang dijalankan di dalam kluster

Perkhidmatan Perkhidmatan yang dijalankan

yang dijalankan secara Niche di hospital-hospital 2 10
secara Niche di dalam kluster

Merangkumi pengurusan aliran

Process pesakit, BWT dan pengurusan
D 6 20
Improvement rekod pesakit secara Kluster, ID
Kluster dan Bil perubatan
JUMLAH 42 100

43 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Casemix Performance

Bahagian A: Tadbir Urus Pemarkahan Markah

maksimum
A1 Pelantikan Penyelaras 1. Ada lantikan ( 1 markah) 1
Casemix Hospital 2. Tiada pelantikan (0 markah)
A2 Pelantikan Jawatankuasa 1. Ada lantikan ( 1 markah) 1
Casemix Hospital 2. Tiada pelantikan (0 markah)
A3 Pelaksanaan Mesyuarat 1. Laksana lebih dari sekali 2
Jawatankuasa Casemix setahun (2 markah)
Hospital 2. Laksana sekali setahun (1
markah)
3. Tidak melaksanakan (0
markah)
Bahagian C: Amalan Penambahbaikan
Kualiti Berterusan (Wajaran 50%)

C1 Peratus ketepatan 1. 90 - 100% (4 markah) 4

dokumentasi klinikal bagi 2. 80 - 89% (3 markah)
diagnosis utama 3. 70 - 79% (2 markah)
4. 60 - 69% (1 markah)
5. <60% atau tidak
melaksanakan audit (0
markah)
C2 Peratus kesempurnaan 1. 90 - 100% (4 markah) 4
dokumentasi klinikal bagi 2. 80 - 89% (3 markah)
diagnosis-diagnosis lain 3. 70 - 79% (2 markah)
4. 60 - 69% (1 markah)
5. <60% atau tidak
melaksanakan audit (0
markah)
C3 Tarikh penghantaran 1. Dihantar pada tahun 2
laporan Audit semasa audit (2 markah)
Dokumentasi Diagnosis 2. Dihantar pada Januari
Klinikal dan Kod tahun berikutnya (1 markah)
Klasifikasi yang lengkap 3. Dihantar selepas 31 Januari
ke JKN tahun berikutnya atau tidak
melaksanakan audit (0
markah)
C4 Bilangan kes kematian 1. ≤ 5 kes (2 markah) 2
dengan darjah keterukan 2. 6 - 15 kes (1 markah)
penyakit 1 (SOI1) dalam 3. ≥ 16 kes (0 markah)
setiap 1,000 kes discaj
pulang ke rumah SOI1
C7 Pelaksanaan latihan 1. Laksana (1 markah) 1
kesedaran casemix 2. Tidak dilaksanakan (0
kepada warga kerja markah)
hospital anjuran hospital

44 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

C8 Pelaksanaan latihan 1. Laksana kedua-dua latihan 2

dokumentasi diagnosis (2 markah)
dan penetapan kod 2. Laksana salah satu latihan (1
klasifikasi anjuran markah)
hospital 3. Tidak laksana (0 markah)
C9 Pelaksanaan latihan 1. Laksana (1 markah) 1
penyelaras casemix 2. Tidak dilaksanakan (0
hospital / jabatan markah)
anjuran hospital

45 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2025

Patient Satisfaction Questionnaire (PSQ – 18)

● Mengandungi lapan belas (18) soalan berkaitan kajian kepuasan pelanggan (KKP).
● Menggunakan 5 mata skala Likert (5-point Likert scale)
● Penilaian adalah merangkumi 7 dimensi;
o Dimensi 1: Kepuasan pesakit
o Dimensi 2: Kualiti teknikal
o Dimensi 3: Sikap Interpersonal
o Dimensi 4: Komunikasi
o Dimensi 5: Aspek kewangan
o Dimensi 6: Waktu bersama dengan doktor
o Dimensi 7: Akses dan keselesaan
● Purata keseluruhan markah diambil kira sebagai pencapaian akhir PSQ-18.

46 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION