Clinical Indicators

Indicators MSQH Targets 2023
Q1 Q2 Q3 Q4
Incidence Rate Surgical Site Infection <2% 0% 0% 0% 0%
Percentage of incidence Rate of
Healthcare Associated Infections (HAI)
<5% 0% 0% 0% 0%
Rate of Carbapenam-Resistant
Enterobacteriaceae (CRE) Infection
<0.1% 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
Q1 Q2 Q3 Q4
Waiting time relative to triage category :
Malaysian Triage Category (MTC) Red seen
immediately
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%
Waiting time relative to triage category :
Malaysian Triage Category (MTC) Green
seen within 90 minutes
>70% 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
Q1 Q2 Q3 Q4
Major Complication Rate during Diagnostic
Coronary Angiogram (Death, Acute
Myocardial Infarction, Stroke)
<1% 0% 0% 0% 0%
Major Complication Rates during
Percutaneous Coronary Intervention
(Death, Acute Myocardial Infarction, Stroke)
<1% 0% 0% 0% 0%
Percutaneous Coronary Intervention (PCI)
within 90 minutes after hospital arrival
“Door to Balloon”
>90% 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
Q1 Q2 Q3 Q4
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%
**Percentage of patients with cancer who have a documented
individualised care plan at the time of treatment.
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%
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%
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%

**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
Q1 Q2 Q3 Q4
**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%
**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%
**Percentage of patients commencing radiationtherapy have
documentedstaging information
93% 100% 99% 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%
Percentage of patients receiving radical radiation therapy treatment for
lung cancer who have motion management in treatment planning
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%

**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.