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Laporan Pencapaian Petunjuk Kualiti MS ISO 9001:2008 HRPZ II (Jul - Dis 2013) 1

PENCAPAIAN PETUNJUK KUALITI JABATAN/UNIT HOSPITAL RAJA PEREMPUAN ZAINAB II, KOTA BHARU

(JULAI - DISEMBER 2013)

1. HRPZ II/CORE/WI-003 – Client Satisfaction 80% pelanggan berpuashati dengan perkhidmatan yang disediakan. (Rujuk Laporan Kajian Kepuasan Pelanggan Luaran (SERVQUAL) (Jul - Dis 2013)

2. HRPZ II/CORE/WI-004 – Waiting Time

90% of patients are attended to within 1 ½ hours of registration at specialist clinic / Emergency Department.

Kajian Masa Menunggu Pesakit di Klinik-Klinik Pakar & Jabatan Kecemasan, HRPZ II (Jul - Dis 2013)

Bil

Klinik/Unit

% Pesakit Yang Dilihat Dalam Tempoh

Masa

% Keseluruhan Pesakit Yang Dilihat Dalam Tempoh Masa

90 Minit < 30 minit 31 – 60 minit 61 – 90 minit

1. ORL 64.12% 29.14% 4.93% 98.20%

2. Kecemasan 72.73% 15.56% 11.70% 100%

3. Dermatologi 100% 0% 0% 100%

4. O&G 6.00% 48.35% 42.35% 96.71%

5. Oftalmologi 32.87% 32.41% 24.27% 89.55%

6. Ortopedik 17.90% 36.60% 42.94% 97.46%

7. Pediatrik 22.40% 42.01% 28.01% 92.43%

8. Pembedahan 32.58% 37.21% 24.58% 94.39%

9. Perubatan 28.75% 35.03% 27.29% 91.09%

10. Radiologi 100% 0% 0% 100%

11. Psikiatri 72.32% 24.38% 3.28% 100%

12. Bedah Mulut 51.12% 31.57% 11.27% 93.98%

13. Respiratori 10.71% 52.77% 32.14% 95.63%

14. Bius 100% 0% 0% 100%

15. Pain 92.10% 7.89% 0% 100%

Purata 96.62%


3. HRPZ II/CORE/WI-006 – Patients Undergoing Elective Surgery Had Attend/Assessed In The Anesthetic Clinic More than or equal to 30% of patients undergoing elective surgery had attend/assessed in the Anesthetic Clinic. (Jul - Dis 2013) Numerator : Total number of Elective Surgery Patients Seen In The Anesthethic Clinic Denominator: Total Number of Elective Cases

Month Numerator (N) Denominator (D) Rate (N/D) x 100%

Jul 123 385 31.95%

Ogos 93 302 30.79%

Sept 137 371 36.93%

Okt 125 362 34.53%

Nov 112 285 39.30%

Dis 162 400 40.50%

Total 752 2,105 35.72%


4. HRPZ II/CORE/WI-007- Incidence Of Physical Food Contamination (sentinel event)

No Physical Food Contamination (Jul - Dis 2013)

Bulan Bil.Pesakit Bil.Hidangan

( x 4 meals/day)

Numerator (Bilangan Insiden

Kontaminasi)

Pencapaian (%) (N/D x 100%)

Jul 20,175 80,700 0 0%

Ogos 20,158 80,632 0 0%

Sept 22,848 91,392 0 0%

Okt 20,961 83,844 0 0%

Nov 23,090 925,360 0 0%

Dis 25,422 101,688 0 0%

Jumlah 132,654 530,616 0 0%

Ulasan :

Tiada insiden kontaminasi fizikal di dalam hidangan pesakit bagi tempoh Jul - Dis 2013.


5. HRPZ II/CORE/WI-008- Neonatal Death from Hospital Acquired Infections

Less than 2% death due to nosocomial infection (Jul - Dis 2013)

Month Jul Ogos Sept Okt Nov Dis Total

Total Admission 263 310 298 337 336 353 1897

Total No. of Death 13 11 10 5 7 9 55

Total Death due to N.I 2 0 0 0 1 2 5

N.I. Death Rate 0.76% 0% 0% 0% 0.29% 0.56% 0.26%


6. HRPZ II/CORE/WI-009 – Low Birth Weight Neonatal Survival Rate

Low Birth Weight Neonatal Survival Rate (Between < 38 weeks gestation) of More Than 85% (Jul - Dis 2013)

Month Jul Ogos Sept Okt Nov Dis Total

Total Admission 4 12 13 8 4 10 51

Total No of Death 0 0 2 0 0 1 3

Total No of Survival 4 12 11 8 4 9 48

LBW Survival Rate 100% 100% 85% 100% 100% 90% 94.1%

Mortality Rate 0% 17% 15% 0% 0% 10.00% 5.9%


7. HRPZ II/CORE/WI-010 - Jabatan Ortopedik

Incidence of Unacceptable Fracture Fixation Requiring Revision Less Than 3% (Jul – Dis 2013)


Julai 0 43 0.00%

Ogos 1 53 1.89%

Sept 1 55 1.82%

Okt 1 52 1.92%

Nov 0 20 0.00%

Dis 0 51 0.00%

Total 3 274 1.09%


8. HRPZ II/CORE/WI-011- Occupational Therapy 95% of New Outpatients Referred Are Given Intervention Within 3 Working Days After Receiving Referrals (Jul - Dis 2013)


Jul 46 46 100%

Ogos 29 30 96.7%

Sept 44 44 100%

Okt 43 44 97.7%

Nov 26 27 96.3%

Dis 31 36 86.1%

Total 219 227 96.4%


9. HRPZ II/CORE/WI-012 - Delivery Rate

70% mother with normal vaginal delivery and without complications must be transfer out to maternity ward within 2 hours after delivery. (Jul - Dis 2013)

Month

No. Of Mother With Normal Vaginal

Delivery (Without Complications)

No. Of Mothers Transfer Out To Maternity Ward Within 2 Hours After

Normal Vaginal Delivery

Percentage

Jul 886 639 72.12%

Ogos 836 611 73.08%

Sept 811 604 74.47%

Okt 831 598 71.96%

Nov 786 575 73.15%

Dis 827 611 73.88%

Total 4977 3638 73.09%

Total number of mothers to be transfer out to maternity ward within 2 hours after normal vaginal delivery (Jul - Dis 2013) = 3638

Total number of mothers with normal vaginal delivery without X 100 = 73.09% complication (Jul - Dis 2013) = 4977


10. HRPZ II/CORE/WI-013-Physiotherapy Indicator : Burns During Delivery of Electrotherapeutic Modalities and thermal agent Standard : No case of burn (sentinel event) (Jul – Dis 2013)

Month No of electrotherapeutic modalities and thermal

agent

No Case of burn

Jul 1342 0

Ogos 820 0

Sept 1209 0

Okt 987 0

Nov 854 0

Dis 916 0

Total 6128 0

KEPUTUSAN No incidence of burn during delivery of electrotherapeutic modalities and thermal agents for the month of July - Dec 2013.


11. HKB/CORE/WI-014- Reject Image Analysis Rate

Rate of rejected images is less than 2.5% of all x-rays performed.

Percentage of Rejected Films against Total Films Used for X-rays Examinations (Jul – Dis 2013)

Total Film Reject

Total Film Used

% Of Film Size Rejected/Total Film Rejection

% Of Rejected Film Size/Total Film Usage

In Size

1300 71100 100% 1.83%


12. HRPZ II/CORE/WI-015 – Social Work

95% daripada kes-kes pesakit yang dirujuk ke Jabatan Kerja Sosial Perubatan akan diambil tindakan tidak lebih daripada 2 hari bekerja daripada tarikh kes diterima (Jul – Dis 2013)

Bulan Jumlah Kes Didaftarkan

Jumlah Kes Mencapai

Penunjuk Kualiti

Jumlah Kes Tidak Mencapai Penunjuk Kualiti

Peratus Pencapaian

Penunjuk Kualiti Sebenar %

Jul 226 226 - 100%

Ogos 204 204 - 100%

Sept 216 216 - 100%

Okt 222 222 - 100%

Nov 159 159 - 100%

Dis 159 159 - 100%

Total 1186 1186 - 100%


13. HRPZ II/CORE/WI-017 - Unit Pendidikan Pesakit

Indikator: 20% pelanggan klinik berhenti merokok yang berdaftar dan mendapat rawatan sekurang-kurangnya 6 bulan berjaya berhenti merokok. (Jul - Dis 2013)

Formula berjaya berhenti merokok :-

Berjaya berhenti = Bilangan berjaya berhenti merokok X 100

Bilangan pesakit berdaftar

Bilangan Berhenti Merokok 2013 = 27 X 100

42

= 64%

Kaunseling & Farmakoterapi KBM

Bulan Pesakit Baru Pesakit Lama Berjaya Berhenti

Jul 5 23 1

Ogos 4 14 3

Sept 10 13 7

Okt 9 12 4

Nov 5 8 4

Dis 9 13 8

Jumlah 42 83 27


14. HRPZ II/CORE/WI-018 - Jabatan Farmasi

92% dispensed of medication at Outpatient Pharmacy less than 30 minutes (Jul - Dis 2013)

Tempoh Kajian Jul Ogos Sept Okt Nov Dis

Jum.Preskripsi 12,422 13,130 11,933 12,644 12,370 11,514

Purata Masa Menunggu (Min)

20.01 18.91 19.50 21.53 27.75 26.22

PURATA ( Jul - Dis 2013 ) = 18.98 minit

Peratus pesakit mendapat ubat dalam masa < 30 Min

97.62% 97.84% 95.99% 97.35% 95.18% 95.84%

PURATA (Jul - Dis 2013) = 96.64%

Hasil Kajian dari Jul - Dis 2013 :

Hasil kajian Julai – Dis 2013 mendapati masa menunggu mencapai standard yang ditetapkan dimana 96.64% pesakit mendapat ubat dalam masa kurang dari 30 minit.


5. HRPZ II/CORE/WI-019- Unit Hasil

Indikator : Kutipan Hasil Pesakit Dalam (Julai - Dis 2013) Standard : Kerajaan - 90% Swasta - 85% Awam - 80% Asing - 40%

MAKLUMBALAS LAPORAN KUTIPAN HASIL (Jul - Dis 2013)

KATEGORI KELAS JUMLAH BIL KUTIPAN TUNGGAKAN JUMLAH PESAKIT %

KUTIPAN

PEN-

GECUALIAN PESAKIT DIKENAKAN BAYARAN

BELUM BAYAR

KELAS 1 55 $ 11,660.00 $ 11,660.00 $ - - 100.00

$ 19,325.50

KERAJAAN KELAS 2 $ - $ - $ - - 100.00

KELAS 3 4 $ 544.50 $ 544.50 $ - - 100.00

JUMLAH 59 $ 12,204.50 $ 12,204.50 $ - - 100.00

KELAS 1 18 $ 18,556.00 $ 15,825.00 $ 2,731.00 3 85.28

SWASTA KELAS 2 37 $ 13,954.00 $ 12,577.00 $ 1,377.00 5 90.13

KELAS 3 199 $ 14,556.00 $ 12,505.00 $ 2,051.00 30 85.91

JUMLAH 254 $ 47,066.00 $ 40,907.00 $ 6,159.00 38 86.91

KELAS 1 34 $ 27,217.00 $ 27,217.00 $ - 100.00

AWAM KELAS 2 44 $ 14,826.50 $ 14,546.00 $ 280.00 1 98.11

KELAS 3 15,039 $ 769,430.30 $ 680,040.50 $ 70,064.30 1,148 88.38

JUMLAH $ 15,117 $ 811,473.80 $ 721,804.00 $ 70,344.30 1,148 88.95

W. ASING KELAS 3 261 $ 162,720.50 $ 108,822.50 $ 53,898.00 96 66.88

JUMLAH 261 $ 162,720.50 $ 108,822.50 $ 53,898.00 96 66.88

JUMLAH BESAR $ 15,691 $ 1,033,464.80 $ 883,738.00 $ 130,401.30 1,283 85.51


16. HRPZ II/CORE/WI-020 - Unit CSSD

Rejection Rate By Consumer Should Be Less Than 1%. (Jul – Dis 2013)

Bulan Penerimaan item kotor

Set Yang Di Reject

% Rejection Rate

Jul 10,760 Set 1 Set 0.00%

Ogos 10,747 Set 3 Set 0.03%

Sept 11,357 Set 4 Set 0.04%

Okt 12,063 Set 3 Set 0.04%

Nov 10,849 Set 2 Set 0.02%

Dis 11,295 Set 2 Set 0.02%

Jumlah 67,071 set 15 set 0.02%


17. HRPZ II/CORE/WI-021 - Jabatan Patologi

Indicator : Laboratory Turn Around Time For Full Blood Count

Standard: 90% of Laboratory Turn Around Time (LTAT) Untuk FBC kurang atau bersamaan 60 minit (less or equal to 60 minutes)

Objektif : Mengkaji “Turn-Around-Time (TAT) dan Laboratory Turn-Around-Time (LTAT)

bagi sampel segera `short turn around time’ (STAT) ujian FBC (Full Blood Count) yang dijalankan di Makmal Integrasi (Core Lab), Jabatan Patologi HRPZ II.

LTAT bermaksud masa yang diperlukan bagi memproses spesimen dari masa penerimaan spesimen di Kaunter Jabatan Patologi sehingga spesimen siap dianalisa di makmal dan dikeluarkan kepada pemohon.

MONTH STANDARD TOTAL OF SPECIMEN

PERFORMANCE ACHIEVED

Jul – Dis 2013 LTAT : < 60 min 46,218 94.21%

Purata masa bagi Laboratory Turn Around Time (LTAT) (Julat) = 0:32 minit (0:02 minit hingga 234 minit)

Is there a shortfall in Quality for this indicator? No


18. HRPZ II/CORE/WI-022 - Jabatan Kecemasan - Thrombolytic Therapy

Indicator: Percentage of Acute ST Elevation Myocardial Infarction (STEMI) Patients Receiving Thrombolytic Therapy within 30 minutes of Presentation at the Emergency Department. (Jul - Dis 2013)

Standard : Not less than 70%

Masa

Bulan

Pesakit yang menerima Thrombolytic Therapy dalam masa 30 minit di

Jabatan Kecemasan

Jumlah pesakit yang menerima Thrombolytic

Therapy di Jabatan Kecemasan

Peratus

Julai 13 18 72.22%

Ogos 17 23 73.91%

September 10 14 71.43%

Oktober 14 19 73.68%

November 17 23 73.91%

DIsember 16 22 72.73%

Jumlah 87 119 73.12%

Is Unit / Department / Hospital an SIQ for this indicator? No


19. HRPZ II/CORE/WI-023 - Jabatan Kecemasan

Indicator: 95% of Ambulance Respond Time Not More Than 30 Minutes within 5 km Radius (Jul - Dis 2013)

Masa

Bulan

Total number of ambulance calls

Ambulance respond time not more than 30 minutes within 5 km

radius

Peratus

Jul 139 139 100%

Ogos 157 157 100%

Sept 120 120 100%

Okt 139 139 100%

Nov 117 117 100%

Dis 153 153 100%

Jumlah 825 825 100%


20. Jabatan Perubatan/Ortopedik/Bedah/Bius/Kardiotorasik/Rehabilitasi

Not More Than 3% Incidence Of Pressure Sore Among Bed Ridden (Jul - Dis 2013)

Displin/Wad No. Of Patient Studied No. Of Patients With Pressure Sores

MEDIKAL 897 0

OTOPIDIK 75 71

1 0

Wad Cempaka Wad Dahlia

BEDAH Wad 26 Wad 28 Wad 29 Wad 30

5 2

20 21

0 0 0 0

BIUS 255 447 54

4 5 0

ICU Intan ICU Teratai Burn

KARDIOTORASIK CICU

77

0

REHABILITASI Wad Rehabilitasi

18

0

Total 1,942 10

a) No. of patient studied - Jul - Dis 2013 = 1,942 b) No. of patient with Pressure Sores - Jul - Dis 2013 = 10 c) Outlier - Jul - Dis 2013 = 0.51%


21. Radicare

Deduction For The Half 2012 (Jan – Dis 2013)

Facilities Engineering Services (FEMS)

NO PERFORMANCE INDICATOR MONITORING TOOLS ACCEPTANCE LEVEL

1. Work Order Analysis : The work order shall be analysed base on the efficiency rating for the following indicator :

a. Planned Preventive Maintenance Through PPM Calendar which mutually agreed by the Customer & Contractor

Efficiency 100% = Acceptance Level

b. Corrective Maintenance To be completed within 12 days of issuance of work request

Efficiency > 90% = Acceptance Level

c. Routine Inspection RI Schedule & RINTIS Efficiency 100% = Acceptance Level

d. Work Request (Completion of Work <12 days)

RINTIS & CMIS Efficiency > 90% = Acceptance Level

e. Respond Time As per TRPI < 30 minutes for Critical and 3 hours for Normal = 100%

2. Deduction Modules/Deduction Report Complaint, PPM,RI,CM,NCR,WR & Statutory Requirement

< 1.4% from monthly revenue

3. Statutory Requirement Monthly Report & Deduction Report 100%

Biomedical Engineering Services (BEMS)


1. Planned Preventive Maintenance PPM Schedule, CMIS and Deduction Report 100%

2. Corrective Maintenance CMIS & Deduction Report Less than 12 days

3. Respond Time RINTIS, CMIS & Deduction Report 2 hours normal & 15 minutes emergency = 100%

4. Work Request (Completion of Work <12 days)

RINTIS & CMIS Efficiency > 90% = Acceptance Level

5. Deduction Modules/Deduction Report Complaint, PPM,RI,CM,NCR,WR & Statutory Requirement

Reduce 50% of Validated Complaint from last year

< 1.4% from monthly revenue

6. Statutory Requirement Monthly Report & Deduction Report 100%

Cleansing Services (CLS)


1. Quality Standard being met ie. No odour, no stain, no dust.

1. Complaint raised during Joint Inspection 1. For Indicator No.1(DF), total demerit point not more than 1% of the total parameter

2. Complaint/NCR (other than Joint Inspection) 2. For indicator No.4 (DF), total demerit point not more than 1% of the total parameter

2. Has general waste being collected Complaint via CMIS 100% collected

3. Has Cleansing being carried out at user locations

Complaint via CMIS 100% done

4. Sufficient Supply of consumables Complaint via CMIS 100% supplied

5. Has general waste being transported Complaint via CMIS 100% collected

Linen and Laundry Services (LLS)

NO PERFORMANCE INDICATOR MONITORING TOOL ACCEPTANCE LEVEL

1. Is clean accepted linen delivered Validated Complaints Less than 2% of the total of the total no. of linen issued for the month.

2. Is adequate accepted linen delivered as required.

Validated Complaints No Shortfall

3. Is adequate accepted linen delivered on time

Validated Complaints 100%

Clinical Waste Management Services (CWM)


1. Adequate supply of MOH approved consumables at each source of generation or locations as per HSIP

Validated Complaints 100% supplied

2. On time collection of clinical waste at location as per HSIP Validated Complaints 100% collected

3. On time transportation of clinical waste from storage area to incinerator as per HSIP

Validated Complaints 100%

4. Compliance to all statutory requirement Validated Complaints 100%


Facilities Engineering Maintenance Services (FEMS)

Total No Done to schedule % Done to schedule

FE-01 Schedule Maintenance - PPM - Routine Inspection

PPM 28676 28676 100%

RI 9919 9919 100%

Total No Done within 15 & 3 days

% Done within 15 & 3 days

FE-02 Breakdown Maintenance - Breakdown repair works completed within 3 days - Breakdown repair works completed within 4-12 days - Breakdown repair works completed within 13-15 days - Breakdown repair works completed >15 days - Provide feedback on works outstanding >15 days - Breakdown outstanding/open

Break down WO

11213

9084 1119 529 481

81.01 9.98 4.72 4.29

Total No Respond on time % Respond on time

FE-03 Respond Time - Complaints and/or requests responded on time (30 mins. for

emergency request and 3 hrs for normal request)? - Response time made by an appropriate person?

Break down WO

11217

11183

99.70%

Total No Attended & Witness

% Attended & Witness

FE-04 Testing and Commissioning - Witnessed the entire testing and commissioning of all new

equipment/system

T&C

89

89

100%

TA Required TA Done % TA Done

FE-05 Technical Advice - Contractor carried out condition appraisal on selected

assets/building/system as requested / as required

TA

421

421

100%

Biomedical Engineering Maintenance Services (BEMS)

Total No Done to schedule % Done to schedule

BE-01 Schedule Maintenance - PPM PPM 3787 3787 100%

Total No Done % Done

BE-02 Breakdown Maintenance - Breakdown repair works completed within 3 days - Breakdown repair works completed within 4-12 days - Breakdown repair works completed within 13-15 days - Breakdown repair works completed >15 days - Provide feedback on wo’s outstanding >15 days - Breakdown outstanding/open

Break down WO

4559

4140 333 13 73

90.81% 7.30% 0.29% 1.60%

Total No Respond on time % Respond on time

BE-03 Respond Time - Complaints and/or requests responded on time (15 mins. for

emergency request and 2 hrs for normal request)?

Break down WO

4504

4490

99.69%

Total No Attended & Witness

% Attended & Witness

BE-04 Testing and Commissioning

- Witnessed the entire testing and commissioning of all new equipment

T&C

301

301

100%

TA Required TA Done % TA Done

BE-05 Technical Advice - carried out condition appraisal on selected equipment as

requested / as required

TA

NA

NA

NA

Cleansing Services (CLS)

Total No.

Done to schedule

% Done to schedule

CL-01 Timely daily cleansing activities

- Cleansing work done on time as agreed Cleansing activities

720225 704602

97.83

CL-02 Timely collection of general waste - General waste collected on time as agreed

Collection 626789 571642

91.20

No. of supplied % No. of supplied

CL-03 Supply of receptacles and consumables - Supply of receptacles – general waste bin, soap dispenser, tissue dispenser

- Supply of consumables – black bag, liquid soap, deodorizers, hand towel and toilet rolls.

Receptacles - -

Consumables 1,153,250 1,149,346

99.66

Done to schedule

% Done to schedule

CL-04 Joint Inspection - Joint inspection carried out with user - No of unsatisfactory

Joint Inspection

648435

641,094

98.87

CL-05 Complaint/NCR - Completed within 2 days - Complete more than 2 days

Complaint 1891 1,556 335

82.28 17.72


Linen and Laundry Services (LLS)

Total No. Qty (pcs) % Delivered & shortfall

LL-01 Delivery of clean linen - Clean linen delivered - Clean linen shortfall

Requested 2,735,392 2,711,759 23,633

99.14

(0.86%) shortfall

Total No. Supplied to schedule

% Supplied to schedule

LL-02 Timely delivered of clean linen - Clean linen supplied on time as agreed

Supplied 16,238 16,238 100

Total No. Done to schedule

% Done to schedule

LL-03 Weighing of linen - Weighing of linen at Linen Store/Sorting are on time as agreed

Weighing

1,120,137.69 1,120,137.69 100

Total No. Qty Rejected % of Rejected

LL-04 Reject Linen – Quantity of linen rejected Rejected 2,711,789 5,627 0.21

Done to schedule

% Done to schedule

LL-05 Timely Collection of Soiled Linen - Soiled linen collection on time as agreed

Collection 109,278 109,278 100

LL-06 Supply of soiled linen & bag carrier - Supplied of soiled linen bag & bag carrier adequate

Supplied

109278/2076

109278/2076

100

Clinical Waste Management Services (CWMS)

Total No. Done to schedule

% Done to schedule

CW-01 Timely collection of clinical waste - Collection done according to agreed scheduled


99.98

Comply to procedure

% Comply to procedure

CW-02 Collection procedure - Collection done according to agreed procedure


99.98

No. of supplied % No. of supplied

CW-03 Supply of receptacles and consumables

- Supply of receptacles – bag holder, bag holder stand adequate - Supply of consumables – yellow bag adequate

Receptacles 7200 7200

100

Consumables

632748 632748 100

Done to schedule

% Done to schedule

CW-04 Timely transportation of clinical waste - Transportation of clinical waste from the central clinical waste store to the incinerator according to the agreed schedule

Transported 365 365

100

Done to schedule

% Done to schedule

CW-05 Weighing of clinical waste - Weighing of waste at central clinical waste store on time as agreed

0 365 365

100

Cleaned % Cleaned

CW-06 Bag holder maintenance - Bag holder cleaned and well maintained

Receptacles 7200 7200

100


22. HRPZ II/CORE/WI-029 - Jabatan Perubatan Forensik

To Release The Right Body To The Right Family Members/Relatives (Jul - Dis 2013)

Bulan Total No. Of Body Receive At Forensic

Department

Total No. Of Body Release To The

Right Family

%

Julai 160 160 100%

Ogos 174 174 100%

Sept 142 142 100%

Okt 148 148 100%

November 154 154 100%

Disember 166 166 100%

Total 944 944 100%

23. Jabatan Dermatologi Infection Rate Of Skin Biopsy Wound Should Not Exceed 2% of Total Number of Skin Biopsy Performed (Jul – Dis 2013)

Bulan Jumlah Skin Biopsy Dilakukan

Infection Skin Biopsy Wound

Infection Rate of Skin Biopsy

Wounds

Julai 49 0 0%

Ogos 29 0 0%

September 17 0 0%

Oktober 29 0 0%

November 20 0 0%

Disember 20 0 0%

Jumlah 164 0 0%


24. Jabatan Bedah Mulut 80% Waiting Time For Trauma Cases Operated Under GA Less Than 2 Weeks (Jul - Dis 2013)

Month Numerator Denominator Achievements (%)

No. Of Trauma Cases < 2 weeks

No. Of Trauma Cases

N x 100

D

Jul 4 11 36.36%

Ogos 6 9 66.67%

Sept 1 4 25.00%

Okt 0 6 0.00%

Nov 1 2 50.00%

Dis 4 4 100.00%

Total 16 36 44.44%

Justification : 1. Insufficient OT Time..... Once a week


25. Unit Pentadbiran Tempoh Pengedaran Surat Rasmi HRPZ II Standard : 80% Surat diedarkan dalam masa 3 hari bekerja (Jul - Dis 2013)

Bulan Jumlah Surat Yang Diterima

Jumlah Surat Yang Diedarkan Dalam Masa 3 Hari Bekerja

Jumlah Surat Yang Diedarkan Lebih Daripada 3 Hari Bekerja

% Surat Yang Diedarkan

Dalam Masa 3 Hari Bekerja

Julai 708 708 0 100%

Ogos 488 488 0 100%

Sept 643 643 0 100%

Okt 605 605 0 100%

Nov 592 592 0 100%

Dis 722 722 0 100%

Jumlah 3758 3758 0 100%

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