Clinical Indicators
| Indicators | MSQH Targets | 2023 | 2024 | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | |||
| Incidence Rate Surgical Site Infection | <2% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |
| Percentage of incidence Rate of Healthcare Associated Infections (HAI) |
<5% | 0% | 0% | 0% | 0% | 0% | 0% | 0.001% | |
| Rate of Carbapenam-Resistant Enterobacteriaceae (CRE) Infection |
<0.1% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |
Island Hospital is dedicated to enhancing the quality and safety of patient care
through continuous improvement efforts. Emphasizing the importance of infection
control as a crucial aspect of healthcare operations, the institution has successfully
maintained a record of zero acquired infections in 2023.
| Indicators | MSQH Targets | 2023 | 2024 | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | |||
| Waiting time relative to triage category : Malaysian Triage Category (MTC) Red seen immediately |
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% | |
| Waiting time relative to triage category : Malaysian Triage Category (MTC) Green seen within 90 minutes |
>70% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | |
In 2023, the emphasis on prompt assessment and treatment of emergency patients
was vital for preserving lives, preventing complications, and enhancing overall
outcomes. This necessitated a collaborative effort among healthcare
professionals, emergency services, and medical facilities to ensure
swift and necessary care for all types of patients.
| Indicators | MSQH Targets | 2023 | 2024 | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | |||
| Major Complication Rate during Diagnostic Coronary Angiogram (Death, Acute Myocardial Infarction, Stroke) | <1% | 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% | |
| Percutaneous Coronary Intervention (PCI) within 90 minutes after hospital arrival “Door to Balloon” | >90% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | |
Island Hospital prioritizes ongoing improvement in patient care quality and safety,
focusing on the Heart Centre. By benchmarking cardiac indicators and adopting
best practices, the hospital ensures patient safety and continually enhances
cardiac services through regular monitoring and evaluation.
| Indicators | 2023 | 2024 | ||||||
|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | ||
| Percentage of patients with cancerreceiving 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% | |
| **Percentage of patients with cancer who have a documented individualised care plan at the time of treatment. | 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% | |
| Percentage of new patients registeredat this HCO with cancer who have documentedstaging prior to the first cancer treatment. | 95.4% | 96.4% | 95.3% | 95.7% | 99% | 98% | 97% | |
| Percentage of patients with a histological/ pathologicalcancer 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% | |
**The indicators suggest that Island Hospital has achieved a higher rate than expected by ACHS
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 | ||||||
|---|---|---|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | ||
| **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% | |
| **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% | |
| **Percentage of patients commencing radiationtherapy have documentedstaging information | 93% | 100% | 99% | 100% | 100% | 100% | 100% | |
| 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% | |
| 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% | |
| 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% | |
**The indicators suggest that Island Hospital has achieved a higher rate than expected by ACHS
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 | 2023 | 2024 | |||
|---|---|---|---|---|---|
| Q3 | Q4 | Q1 | Q2 | Q3 | |
| **Cancellation of procedure after arrival due to administrative/ organizational reasons (L) |
0% | 0% | 0% | 0% | 0% |
| Patients who experience an adverse event during care delivery | 0% | 0% | 0% | 0% | 0% |
| Unplanned return to operating room on same day as initial procedure | 0% | 0% | 0% | 0% | 0% |
| **Unplanned transfer or overnight admission related to procedure | 0% | 0% | 0% | 0% | 0.15% |
| Time to balloon opening within 90 minutes | 100% | 100% | 100% | 100% | 100% |
| **Reported parenteral exposures sustained by staff | 0% | 0% | 0% | 0% | 0% |
| Reported non-parenteral exposures sustained by staff | 0% | 0% | 0% | 0% | 0% |
| Contrast extravasation during an IV contrast enhanced CT procedure requiring specialist review |
0.52% | 0% | 0.32% | 0% | 0% |
| Contrast extravasation during an IV contrast enhanced CT procedure requiring medical review |
0% | 0% | 0% | 0% | 0% |
** Indicates the Island Hospital is statistically significantly ‘different’ to all other organizations submitting
data to ACHS where the result is desirably lower or higher than the expected rate
Regular assessment and monitoring of clinical outcomes within cardiology services
enable healthcare providers to personalize treatment strategies, refine supportive
care interventions, and elevate overall patient outcomes in cardiology care.