1. Infection Control

According to the information provided by the Centers for Disease Control and Prevention (CDC), approximately 1 in 31 hospitalized patients experiences a Healthcare-Associated Infections or HAI. . Monitoring of HAIs proves to be critical and crucial in any healthcare facilities/ Hospitals aiming to eliminate and minimize occurrence of infections.

Notably, our Hospital, Sunway Medical Centre Velocity boasts a track record of zero-incidence rate for Blood bloodstream infections (BSIs), and Ventilator-associated pneumonia (VAP), with no reported cases of Vancomycin-resistant Enterococci (VRE) infections, over three consecutive years. Besides BSI, VAP and VRE, the Hospital Surgical Site Infection (SSI) rates post-Total Knee Replacement (TKR) reveals a consistent zero-incidence rate from 2021 to 2023.

This outcome is attributable to our nurses’ and clinicians’ stringent adherence to protocols designed to eliminate the likelihood of infections within the Hospital. Emphasis on hand hygiene, coupled the utilization of sterile instruments and equipment, contributes significantly to this outcome.

Our team of Infection Control Nurses and link officers, strategically distributed throughout all clinical departments and supported by a strong clinical leadership team, develops and strengthens protocols designed to prevent HAIs. To guarantee extensive coverage, our comprehensive strategy includes regular training sessions for all healthcare personnel. More than 95% of our clinical staff participate in thorough training, arming them with essential knowledge and skills required for infection prevention and control measures.

Internal periodic audits are planned, and carried out to assess and ensure adherence. This initiative is a key component of the Hospital's commitment to provide patients with a HAI-free environment, instilling confidence in their well-being as they return home.

Quality Measures / Period

2021
(January – December)

2022
 (January – December)

2023
 (January – December)

Target / Limit*

Outcome

Haemodialysis AV-fistula access-associated Blood Stream Infection

0%

0%

0%

0%

Met

Catheter-Related Blood Stream Infection (CRBSI) within the ICU

0

0

0

<5 per 1000 catheter days

Met

VRE infection within the ICU

0%

0%

0%

0.1%

Met

Ventilator-associated pneumonia (VAP) within the ICU

0

0

0

10 per 1000 ventilator days

Met

Surgical Site Infection Post-Total Knee Replacement (TKR)

0%

0%

0%

≤ 2%

Met

*with reference to accreditation targets

 

  1. Health Information Management System (HIMS) / Medical Records

In accordance with the Malaysian Medical Council (MMC) Guideline pertaining to Medical Records and Medical Reports, there exists a pressing need for timely preparation and availability of Medical Reports for collection by patients, their next of kin, or authorized agents. As a best practice, and with an emphasis on promptness, clinicians, as per the Guideline, generally have a period of six (6) weeks, starting from the time the Records Officer processes the request, to furnish a comprehensive report.

Deviating from the original six-weeks’ timeline, our Hospital took proactive steps to aim for report completion within a two to four-weeks window, with the goal of expediting these requests. Despite the shorter timeframe, the Hospital has achieved commendable results, showing a compliance rate of 98% in 2021 and 99% in 2022 and 2023. Our Medical Records Department remains steadfast in ensuring swift processing of requests from patients or their authorized representatives.

This highlights the Hospital's firm dedication in providing efficient and quality services, extending beyond clinical treatment to encompass every aspect of a patient's visit or admission to the hospital.

Quality Measures / Period

2021
(January – December)

2022
 (January – December)

2023
 (January – December)

Target / Limit*

Outcome

Percentage of medical reports prepared within 2 to 4-weeks from date of request.

98%

99%

99%

90%

Met

*with reference to accreditation targets

1 https://www.cdc.gov/hai/data/index.html
2 MMC Guideline 002/2006