- Introduction
- Organization Chart
- Functional Chart
- Departmental Objective
- Services
- Operational Hours
- Contact Us
- Download
- Quality Assurance Program
- Quality Bulletin
- Quality Activity
Quality Improvement and Patient Safety Department in Hospital Al-Sultan Abdullah UITM was established on 1st March 2020 with the aim to control and monitor implementation of quality programs in Hospital Al-Sultan Abdullah UITM. Among the activities monitored are incident reporting activities, internal audit, SOP and policy workshops, credentialing and privileging, morbidity and mortality, Key Performance Indicator (KPI) monitoring, Creative Innovative Group (KIK) Program and other activities that related.
- Facilitate continuous quality improvement through regular monitoring and evaluation of quality activities.
- Ensuring compliance to accreditation and certification standards through the implementation of training and audit activities.
- Develop and implement patient safety activities that aligned with WHO Patient Safety Solutions and Malaysian Patient Safety Goals
- Foster and maintain a culture of patient safety among the staff at Hospital Al-Sultan Abdullah.
Credentialing & Privileging (C&P)
Review and manage the process of amendment of official documents of departments at UITM Hospital such as policies, procedures, work Instructions, forms
Quality Assurance Activities of HASA UiTM Key Performance Indicators (KPIs)
- Credentialing involves establishing standards and evaluating individuals in a specific field or procedure. It serves as recognition of a medical practitioner's qualifications and professional training
- Privileging refers to the authorization granted by the hospital allowing a medical practitioner to administer treatment or conduct procedures on patients within the hospital premises, based on their training, qualifications, experience, and competency.
- The Credentialing & Privileging initiative was initiated in 2001 in compliance with the directives of the Ministry of Health Malaysia. Its objective is to ensure that healthcare professionals performing procedures possess efficiency and proficiency in their practice.
- HASA UiTM C&P application coordinator (C&P secretariat)
- Verification and approval of C&P within HASA UiTM.
- Management of Credentialing & Privileging documentation.
- Incident Reporting, also referred to as event monitoring or occurrence reporting, involves the documentation of incidents within healthcare settings.
- Staff engaged in quality activities are mandated to report occurrences to identify weaknesses and root causes in the healthcare system, aiming to enhance patient safety. This proactive approach enables hospital institutions to implement preventive and remedial measures, effectively reducing the likelihood of incidents recurring or occurring.
- Addressing the rising incidence rate is crucial to safeguard the safety of patients, their families, and staff, while concurrently enhancing the quality of care and services. This effort contributes to maintaining the positive reputation and image of the hospital
- Facilitate and oversee the execution of Root Cause Analysis (RCA) at the hospital level.
- HASA UiTM Mortality & Morbidity Committee Secretariat
- Coordinate the reporting for Mortality & Morbidity (M&M) cases.
- Organize and conduct M&M reviews at the hospital level.
- Distribute the agreed-upon results to all pertinent departments.
- Coordinate MDAC Meetings at hospital level
- Monitoring adherence to WHO Global Patient Safety Initiatives.
- Monitoring compliance with Malaysian Patient Safety Goals.
- Organizing and implementing workshops focused on risk management
- MSQH Accreditation
▪ISO and HACCP certification - Hospital Mesra Ibadah
▪Baby Friendly Hospital - Pain Free Hospital Internal audit
- Organizing audit courses
- Carry out audit implementation and reporting at HASA UiTM
- Coordinate activities and assist group members in understanding KIK
Review and manage the process of amendment of official documents of departments at UITM Hospital such as policies, procedures, work Instructions, forms
Quality Assurance Activities of HASA UiTM Key Performance Indicators (KPIs)
- ▪Supervise and oversee the Key Performance Indicators (KPIs) of departments within HASA UiTM
- ▪Hospital Performance Indicators for Accountability (HPIA)
- Organize clinical audit programmes
- Supervise and monitor clinical practices/services
- Coordinate , analyse and report customer satisfaction survey at HASA UiTM level
- Managing the dissemination and publication of information relevant to department.
- Supervising human resources for QIPS staff.
- Handling financial documentation within the department.
- Ensuring the competency of QIPS staff.
- Overseeing general administrative tasks (Secretariat/Department Meeting Coordination, Managing invitations and attendance for meetings/workshops, Organizing space bookings, food arrangements, and technical requirements for programs/workshops/meetings).
| MONDAY TO FRIDAY | 0800 AM UNTIL 1700 PM |
| PUBLIC HOLIDAY AND WEEKEND | CLOSED |
 |
: | PROF.MADYA DR. JULINA @ AZIMAH MOHD NOOR (DU56) |
| : | HEAD OF DEPARTMENT | |
| : | julina989@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14501) |
 |
: | DR. FATIM ZULAIKA BINTI MOHAMED ALI (UD54) |
| : | DEPUTY HEAD OF DEPARTMENT / MEDICAL OFFICER | |
| : | fatimzulaika@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14506) |
 |
: | DR. MAHFUZAH BINTI RUSELAN (UD47) |
| : | MEDICAL OFFICER | |
| : | mahfuzah@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14505) |
 |
: | DR. FARAH FARHANA BINTI HARITH (UD43) |
| : | MEDICAL OFFICER | |
| : | ffarhana@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14503) |
 |
: | MOHD ADIFFER BIN OTHMAN (N41) |
| : | ASSISTANT REGISTRAR | |
| : | adiffer@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14504) |
 |
: | DAYANA IZNI BINTI SHARIF (U32) |
| : | STAFF NURSE | |
| : | d_izni@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14502) |
 |
: | NUR AIMI BINTI KAMARUL AIZAN (U29) |
| : | STAFF NURSE | |
| : | nuraimi_aizan@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14502) |
 |
: | MASZANINA BINTI AZHAR (N29) |
| : | EXECUTIVE OFFICER | |
| : | maszanina@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14515) |
 |
: | MUHAMMAD HASHIM BIN DAMIRI (N19) |
| : | CLERK | |
| : | mdhashim@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14516) |
 |
: | MUHAMAD RAIZUDDIN BIN MOHD ROSMI (N19) |
| : | CLERK | |
| : | raizuddin@uitm.edu.my | |
| : | 03-3396 3000 (Ext No : 14516) |
| NO | TITLE | FORMS | |
|---|---|---|---|
| 1 | INCIDENT REPORTING & ROOT CAUSE ANALYSIS | 1 | INCIDENT REPORTING SYSTEM |
| 2 | MORTALITY & MORBIDITY | 2 | MORTALITY & MORBIDITY RECORD FORM (DEPARTMENT LEVEL) |
| 3 | MORTALITY & MORBIDITY RECORD FORM (HOSPITAL LEVEL) | ||
| 3 | CREDENTIALING & PRIVILEGING (C&P) | 4 | APPLICATION C&P (SPECIALIST/CONSULTANT) |
| 5 | APPLICATION C&P (VISITING SPECIALIST_CONSULTANT) | ||
| 6 | APPLICATION C&P (MO-MEDICAL OFFICER) | ||
| 7 | APPLICATION C&P (NURSE_AMO_AHP) | ||
| 8 | APPLICATION C&P (MO-POSTGRADUATE STUDENT FROM ANOTHER UNIVERSITY) | ||
| 9 | APPLICATION FOR ADDITIONAL CLINICAL PRIVILEGES | ||
| 10 | APPLICATION FOR RENEWAL OF C&P | ||
| 4 | KPI HUiTM | 11 | PERFOMANCE INDICATORS SYSTEM |
| 5 | OPENKM | 12 | DOCUMENT MANAGEMENT SYSTEM |
