Clinical Indicators
| Indicators | MSQH Targets | 2023 | 2024 | 2025 | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | ||||||
| Incidence Rate Surgical Site Infection | <2% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0.7% | ||||
| Percentage of incidence Rate of Healthcare Associated Infections (HAI) |
<5% | 0% | 0% | 0% | 0% | 0% | 0% | 0.001% | 0% | 0% | 0.1% | ||||
| Rate of Carbapenam-Resistant Enterobacteriaceae (CRE) Infection |
<0.1% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | ||||
We prioritize infection control and prevention, aiming for near-zero hospital-acquired
infections (HAIs). Through strict hygiene protocols, real-time monitoring, and staff
training, we protect patients and enhance care quality across all departments.
| Indicators | MSQH Targets | 2023 | 2024 | 2025 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | |||||
| Waiting time relative to triage category : Malaysian Triage Category (MTC) Red seen immediately |
100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | |||
| Waiting time relative to triage category : Malaysian Triage Category (MTC) Yellow seen within 30 minutes |
>85% | 100% | 99% | 100% | 99.3% | 99.3% | 99% | 99% | 99% | 100% | |||
| Waiting time relative to triage category : Malaysian Triage Category (MTC) Green seen within 90 minutes |
>70% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | |||
We ensured timely care across all triage levels—Red (critical), Yellow (urgent), and
Green (non-urgent)—by closely monitoring patient wait times and prioritizing response
efficiency in our emergency departments.
| INDICATORS | MSQH TARGETS | 2023 | 2024 | 2025 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | |||||
| Major complication rate during diagnostic coronary angiogram (death, acute myocardial infarction, stroke) | <1% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| Major complication rates during percutaneous coronary intervention (death, acute myocardial infarction, stroke) | <1% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| Percutaneous Coronary Intervention (PCI) within 90 minutes after hospital arrival “Door to Balloon” Time | >90% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 75% | – | 100% | |||
Through strict protocols, real-time monitoring, and a patient-centered approach, we
strengthened safety standards to drive better outcomes in diagnosis, treatment, and
recovery across the full spectrum of cardiac care.
| Indicators | 2023 | 2024 | 2025 | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | ||||
| Cancellation of procedure after arrival due to administrative/ organizational reasons (L) | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| Patients who experience an adverse event during care delivery | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| Unplanned return to operating room on same day as initial procedure | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| Unplanned transfer or overnight admission related to procedure | 0% | 0% | 0% | 0% | 0.15% | 0% | 0% | 0% | |||
| Time to balloon opening within 90 minutes | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| Reported parenteral exposures sustained by staff | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| Reported non-parenteral exposures sustained by staff | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| Contrast extravasation during an IV contrast enhanced CT procedure requiring specialist review | 0.5% | 0% | 0.3% | 0% | 0% | 0% | 0% | 0% | |||
| Contrast extravasation during an IV contrast enhanced CT procedure requiring medical review | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
Regular assessment and monitoring of clinical outcomes enable cardiology services and
healthcare providers to tailor treatment strategies, optimize supportive care interventions,
and enhance overall patient outcomes in cardiac care.
| Indicators | 2023 | 2024 | 2025 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | ||||
| Percentage of patients with cancer receiving systemic cancer therapy who have had their treatment clinically verified by a cancer pharmacist before its administration / self-administration | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | |||
| **Percentage of patients with cancer who have a documented individualised care plan at the time of treatment. | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | |||
| Percentage of patients with cancer who received systemic anticancer therapy according to an approved systemic anticancer protocol. | 94.7% | 94.9% | 94.2% | 93.2% | 92.7% | 92% | 93% | 91% | 92% | 91% | |||
| Percentage of new patients registered at this HCO with cancer who have documented staging prior to the first cancer treatment. | 95.4% | 96.4% | 95.3% | 95.7% | 99% | 98% | 97% | 100% | 95% | 94% | |||
| Percentage of patients with a histological/ pathological cancer diagnosis who commenced first treatment within 30 days of that diagnosis. | 85.1% | 89.3% | 90.6% | 84.6% | 89.3% | 83.7% | 88.3% | 89.7% | 89.7% | 89.7% | |||
Regular assessment and monitoring of these clinical outcomes help oncologists and
healthcare providers tailor treatment strategies, optimize supportive care interventions,
and improve overall patient outcomes in cancer care.
| Indicators | 2023 | 2024 | 2025 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | ||||
| **Percentage of patients whose ready to care date to the date of commencing radical radiation therapy is more than 3 days | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| **Percentage of patients whose ‘ready for care’date to the date of commencing palliative radiation therapy is more than 1 day. | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| **Percentage of patients commencing radiationtherapy have documentedstaging information | 93% | 100% | 99% | 100% | 100% | 100% | 100% | 100% | 99.3% | 98.7% | |||
| Percentage of patients having radical radiation therapy for Category 1 tumour have unscheduled prolongation of their treatment more than 2 days | 0% | 0% | 3% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |||
| Percentage of patients receiving radical radiation therapy treatment for lung cancer who have motion management in treatment planning | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | |||
| Percentage of NCCN “high or very high risk” prostate cancer patients receiving radical radiation therapy commencing Androgen Deprivation Therapy planned for more than a year | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | |||
By benchmarking clinical outcomes against region peers and implementing targeted
quality improvement efforts, healthcare institutions can strive to
achieve and maintain excellence in cancer care delivery.
| Indicators | 2024 | 2025 | ||||
|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | |
| Failure to reach caecum / neo-terminal ileum due to inadequate bowel preparation | 0% | 0% | 0% | 0% | 0% | 0% |
| Failure to reach caecum due to pathology encountered | 1.3% | 1.0% | 0.7% | 0% | 0% | 1.3% |
| Treatment for possible perforation post-polypectomy | 0% | 0% | 0% | 0% | 0% | 0% |
| Treatment for possible perforation post-colonoscopy | 0% | 0% | 0% | 0% | 0% | 0% |
| Post-polypectomy haemorrhage | 0% | 0% | 0% | 0% | 0% | 0.3% |
| Adenoma Detection Rate | 14.3% | 16.6% | 16% | 19.7% | 23% | 19.7% |
| Possible perforation after oesophageal dilatation | 0% | 0% | 0% | 0% | 0% | 0% |
| Aspiration following endoscopy | 0% | 0% | 0% | 0% | 0% | 0.3% |
| Sedation in GI endoscopy | 1% | 0% | 1% | 1% | 1% | 0% |
We are committed to delivering high-quality gastroenterology care by
continuously benchmarking key indicators, optimizing procedural efficiency,
and ensuring adherence to best practices.
| Indicators | 2024 | 2025 | ||||
|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | |
| Booked patients who fail to arrive | 0% | 0% | 0% | 0% | 0% | 0% |
| Cancellation after arrival due to pre-existing medical condition | 0% | 0% | 0% | 0% | 0% | 0% |
| Cancellation of procedure after arrival due to administrative or organisational reasons | 4% | 5% | 5% | 4% | 1% | 0% |
| Patients who experience an adverse event during care delivery | 0% | 0% | 0% | 0% | 0% | 0% |
| Unplanned return to operating room on same day as initial procedure | 0% | 0% | 0% | 0% | 0% | 0% |
| Unplanned transfer or overnight admission related to procedure | 0% | 0% | 0% | 0% | 0% | 0% |
| Departure without an escort | 0% | 0% | 0% | 0% | 0% | 0% |
| Percentage of departure without an overnight carer | 0% | 0% | 0% | 0% | 0% | 0% |
By closely monitoring key patient indicators in gastroenterology day care, we ensure
every procedure is efficient, safe, and aligned with best practices to drive better patient
outcomes, faster recoveries, and a higher standard of digestive health care.