STRENGTHENING THE TRAINING OF HOs & MOs IN EFFORT TO PRODUCE MORE SPECIALISTS FOR THE COUNTRY: ROLE...

STRENGTHENING THE TRAINING OF HOs & MOs IN EFFORT TO

PRODUCE MORE SPECIALISTS FOR THE COUNTRY:

ROLE OF HOSPITAL DIRECTORS

MESYUARAT TEKNIKAL PROGRAM PERUBATAN8-9 APRIL 2014

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DR. HJ. ROHAIZAT BIN HJ. YONMEDICAL DEVELOPMENT DIVISION

MEDICAL STUDENT

HOUSE OFFICER

MEDICAL OFFICER SPECIALIST SUB-

SPECIALIST

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MANPOWER PLANNING: CONTINUUM

House Officers

HOUSE-OFFICERS: MAIN ISSUES

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Intake of HOs: Medical Grads Production vs. Vacancy of Posts

Redefining Training Norm: Redistribution of HO Posts

New HOs Hospital Level Orientation

Flexi Working System

New Disciplines Introduced: Psychiatry & Primary Care

MEDICAL GRADUATES

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Medical graduates: Local & abroad378 universities worldwide (in 35 countries)

Variation in quality related to: Curriculum, training/clinical exposure Exposure to diseases, especially tropical diseases Different languages spoken/local cultures

Increasing number of medical graduates especially since 2008

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NUMBER OF NEW HOUSE OFFICERS APPOINTED (1998 – 2013)

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

1000

2000

3000

4000

5000

6000

Local Universities Graduates Overseas Universities Graduates Total

Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Local Universities 360 372 477 519 830 850 907 945 993 1,104 1,449 1,726 1,864 1,964 2,180 2,588

Overseas Universities 619 433 345 241 167 109 129 104 66 186 877 1,332 1,388 1,600 1,563 2,403

Total 979 805 822 760 997 959 1,036 1,049 1,059 1,290 2,326 3,058 3,252 3,564 3,743 4,991

Continuous intake by SPA throughout the year

HO posts: Total = 10,803 posts (10,360 in MOH) HO posts filled: 9,789 (90.6%) – as of 31.1.2014 HO vacancies: 1,014 (9.4%)

New Medical graduate interviewed by SPA (Feb 2014) About 1,000 waiting to be appointed.

Expected number of local medical graduates…

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STATUS OF HO POSTS (UD41): 31.1.2014

Year Public LocalMedical Schools (IPTA)

Private Local Medical Schools (IPTS)

Total Number of Students(IPTA + IPTS)

2017 1,698 2,283 3,981

2016 1,471 1,707 3,178

2015 1,375 1,531 2,906

PRELIMINARY DATA…

About 50% (45-60%) of HO started housemanship in Jan/Feb/Mac 2012 able to complete training within 2 years in 2014 (Note: Preliminary data/not accurate as only cover 2 months)

The others 50%, take more than 2 years for various reason: Leave taken in excess e.g. maternity leave, getting married, etc. MIA Extended to complete log book Requested transfer causing disruption of training Extended due to incompetency

CLOGGING THE UD41 POSTS BACKLOG!

….IHM IS CONDUCTING A DETAIL STUDY

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HO COMPLETING TRAINING

Facilitate to vacant the UD41 post for HO as soon as they finish training: Facilitate promotion process from UD41 to UD44 once HO completed

Housemanship Or sandarkan to UD44 post while waiting for urusan kenaikan

pangkat – so new HO can fill in UD41 post Submit Full Registration to MMC quickly

Continuous monitoring of HO’s attendance/disciplinary issues – action to be taken by Unit Sumber Manusia/TP Hospital (Pengurusan)

Proper documentation on problematic HOs pertaining to their assessment/competency/disciplinary etc.

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Current Training Norm for HO based on acute beds (minus ENT, Ophthalmology, Subspecialty wards, etc.) Number of Acute Beds: total = 35,664 beds (in MOH: 32,665) Number of HO posts: total = 10,803 posts (in MOH: 10,360)

Ratio = 1 : 3.3

Redefine HO training norm: Include other factors e.g. training received in OT, Day Care, Out Patient Clinic, Procedure

Room, etc. Stage 1: create Correction Factor (discipline specific, to calculate virtual bed for more

accurate training norm) Stage 2: calculate Virtual Bed & number of HOs according to 1 : 4 ratio for each discipline Stage 3: redistribution of post to all training hospitals

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REDEFINING TRAINING NORM: REDISTRIBUTION OF HO POST

Acute Bed Ratio Number of HO

35,664 1 : 3.3 10,80335,664 1 : 3.5 10,19035,664 1 : 3.8 9,38535,664 1 : 4.0 8,916

Cannot be done abruptly as currently 9,789 HOs

occupying the post

REDISTRIBUTION OF UD41 POST BETWEEN MOH TRAINING HOSPITALS: EXAMPLE

No Training Number of Number Number Existing Redistribution Difference Hospitals Official of of Approved of Post According to Between A & B Beds Virtual Beds HOs Required Posts Ratio of Existing Post

Ratio 1 : 4 (A) to Virtual Bed (B)

i.e. post required 1 HTF, Kangar 404 705 176 189 181 -82 HSB ,Alor Star 856 1315 329 390 337 -533 HSAH, Sg Petani 550 932 233 206 239 334 H. Kulim 310 637 159 101 163 625 H. Pulau Pinang 1107 1444 361 510 370 -1406 H. Seberang Jaya 314 637 159 245 163 -827 H. Taiping 608 892 223 188 229 418 HRPB, Ipoh 990 1475 369 408 378 -309 H. Teluk Intan 548 848 212 159 218 59

10 H. Sri Manjung 270 570 142 203 146 -5711 HKL 2115 2519 630 745 646 -9912 H. Putrajaya 310 567 142 171 145 -2613 HTAR, Klang 893 1559 390 465 400 -6514 H. Selayang 880 1239 310 318 318 015 H. Serdang 555 930 232 213 239 2616 H. Kajang 326 615 154 159 158 -117 H. Sungai Buloh 622 987 247 224 253 2918 H. Ampang 444 787 197 180 202 2219 HTJ, Seremban 850 1236 309 408 317 -9120 HTAN, Kuala Pilah 314 543 136 184 139 -4521 H. Melaka 1041 1604 401 414 412 -222 HPSF, Muar 550 797 199 220 205 -1523 HSAJB 989 1655 414 336 425 89

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Efficient posting & rotation of HOs between departments

After redistribution exercise:Some hospitals will get more UD41 postsSome will have their UD41 post reduced

But, service delivery still by MO/SpecialistHOs undergo training (not extra pair of hand)

Maximizes training in areas other than main wards e.g. training received in OT, Day Care, Out Patient Clinic, Procedure Room, etc.

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ROLE OF HOSPITAL DIRECTOR

HOSPITAL LEVELORIENTATION COURSE

HO report duty: 2nd & 4th week of each month after induction course

To undergo 5 days of hospital level orientation Uses generic framework for orientation (next

slide) To include Basic Life Support (BLS) course

At respective hospital Can combine with other hospital’s health workers to

maximise each time the course is done

GENERIC FRAMEWORK-1: ORIENTATION COURSE TIMETABLE

8AM 9AM 10AM 11AM 12PM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM

MON INTRO HOSPITAL DIRECTOR LUNCH HEALTH & SAFETY

TUE MEET HOD

IT/DOCUMENTATION OF MEDICAL NOTE LUNCH RADIOLOGY DEPT TAGGING

WED PATHOLOGY DEPT LUNCH PHARMACY TAGGING

THUR BASIC LIFE SUPPORT LUNCHBASIC LIFE SUPPORT

+ CLINICAL SKILL TRAININGe.g. blood taking, etc.

TAGGING

FRI BLOOD TRANSFUSION RECORD OFFICE LUNCH HR DEPT TAGGING

SAT TAGGING

SUN OFF DAYOR

GENERIC FRAMEWORK-2: ORIENTATION COURSE CONTENT

Introduction- Organisational chart- Map/location of various departments- Services- Introduction by HR Department – various forms to be filled Hospital Director- Welcome speech-Housemanship training overall structure-Expectation etc.- Laporan Nilaian Prestasi Tahunan (LNPT)

Health & Safety- Immunisation (Hepatitis B, H1N1 etc.)- Fitness to practice (physical & psychiatric illness)- Occupational hazards & safety precautions- Needle stick injury & sharp bin- Waste (clinical, non-clinical)-Infection Control, etc

IT & Medical Notes Documentation-Intro to IT system in IT based hospitals-Guide on proper documentation, writing medical notes (by physician / paediatrician)-Medicolegal implication, etc

Radiology-Requesting imaging – indication, appropriate imaging, urgency etc-Forms – type of forms, information required, etc-Tracing imaging report, etc

Patology-Requesting investigations – indication, appropriateness, urgency etc-Forms – type of forms, information required, etc-Tracing investigation report, etc

Pharmacy-Prescribing, prescribing error-Class of drugs (A,B,C)-Antibiotic protocol-DDA

Blood transfusion-Group Cross Match, Group & Save-Requesting blood product-Blood transfusion protocol & DIVC regime-Transfusion error & its management, etc



Others-Clinical skills e.g. blood taking, urinary catheterisation, Ryles Tube, IV cannulation, etc.-Soft skills/Communication skills-Medical ethics e.g. patient’s right, confidentiality, autonomy, beneficence, consent, cultural concern, negligence, chaperone, etc.-Right attitude for doctors

Record Office-Admission, discharge, discharge summary-Coding / ICD-10-Death certifícate, burial permit, birth form-Related protocol/SOP HR Department-Leaves, pay roll, attendance, punch card, confirmation in service, full registration, disciplinary actions, etc.

Basic Life Support-Need to train more instructor-Instructor can include paramedics, staff nurses, etc.-Can be combined with other staff to maximise the course, more worthwhile

Organises hospital orientationEngage relevant Depts to enrich the Orientation Course

Regular dialog with new Hos

Deliver expectation of MOH & Hospital DirectorAs a Civil Servant: follow General Order (rules & regulation)HO training programme: need to complete training – to be competent & safe doctors

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INPUTS RECEIVED

Housemanship Training Hospital

House Officers

Other Stake Holders

IHSR Research

MOH Head of Services for 7

Basic Disciplines

Anaesthesia

Emergency Medicine

INPUTS FOR ENHANCEMENT OF FLEXI SYSTEM

Phone calls/letters

from HOs,parents & spouses

of HOs

Various top MOH

Officers-HO meetings

e.g. HospTawau 10.5.2013

HOs,parents & spouses of HOs come in

person to MOH

HQ/JKN

Hospital DirectorsHousemanship

Programme Coordinators

HODs & Senior

Clinicians

Medicine

Surgery

Paediatric

Orthopaedic

O&G

Articles written by

HOs to Newspapers

Various continuous inputs from all stake holders including HO

INPUTS FOR ENHANCEMENT OF FLEXI SYSTEM

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Meeting with HKL Medical Dept @ 23.5.2013Meeting with States Health Deputy Director (Medical) & Director of HKL @ 8.7.2013

Meeting with Head of Services, selected Hospital Directors & Senior Consultants @ 10.7.2013

Meeting with Head of Services, selected Hospital Directors & Senior Consultants @ 1.8.2013 – formulation of generic Framework of Flexi System

Specialist Conference at Avillion Legacy Hotel, Melaka on 20-22.9.2013

Meeting with States Health Deputy Director (Medical)& Director of HKL @ 7-8.10.2013

Meeting with TPKN(P), Head of Services, all 42 Housemanship Training Hospitals’ Directors, Specialists & HO Training Coordinator @ IKN 23.10.2013

Briefing to Health Minister in Melaka–MOH Way Forward 18.10.2013

MMA InternationalSeminar on HO Training / Minister’s Speech - 16.11.2013

Briefing Sessions to House Officers:–Southern Region @ Hosp Muar 19.11.2013 –Central Region @ Hosp Sg Buloh 2.12.2013–Northern Region @ Seberang Jaya 16.12.2013–East Coast Region @ HSNZ 23.12.2013

–Sabah State @ HQE

–Sarawak State @ HUS – Mesy Khas KPK @ Johor – Mesy TPKN(P) & TP HKL with TKPK(P) & PPP @ Langkawi

Existing Flexi System to be further strengthened! Not to reintroduce on-call system (90-120 Hrs)

There is no specific model/specific timetable that fit all Hospitals / Disciplines

The need to establish a generic framework which is flexible to meet all basic principle/requirement of Flexi System

Emphasis on more accountability in patient care & more time spent during office hours for training

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FEEDBACK & CONCENSUS

SUMMARY: GENERIC FLEXI SYSTEM FRAMEWORK

21* Each discipline/hospital is given flexibility to modify the flexi system accordingly tosuit its own local environment as long as it conforms with generic framework above

Duration: average of 65-75 hours per week for 4 months posting To implement Modified Flexi System

For ward based discipline – may implement 3 sessions as per example in the next slide (1 normal working hours + 2 flexi hours)

For non ward based discipline – implement existing system as in ED Dept. May also be applicable for Anaesthesia.

Shall not work continuously for more than 16 hours per session (without breaks) All days are considered as working days inclusive of Public Holidays (PHs) &

weekends (as HOs are undergoing training) Entitled for replacement day off if working on PH HO shall be given 1 full day off per week – can fall on any day Protected Post-night duty off (afternoon off) Protected time for CME must be provided & HO expected to attend at least 75% of

department’s CME sessions Emphasis on more accountability in patient care & more time spent for training

during office hours

7am-12pm 12pm-4pm 4pm-10pm 10pm-7am

5 hrs 3 hrs (-1 hr lunch) 6 hrs 9 hrs

Table HO 1 hrs/day

MON MF2 (NORMAL + EVENING) 14

TUE MF1 8

WED MF2 (NORMAL + EVENING) 14

THU MF3 MF3 (NIGHT) 17

FRI Post-night duty till 12pm OFF 5

SAT OFF 0

SUN MF3 MF3 (NIGHT) 14

Cumulative hours for week 72

EXAMPLE OF MODIFIED FLEXI SYSTEM- MEDICAL DEPT, HKL

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Refined schedule to enable more time to be spent during day time/office hours – to maximise attendance to ward rounds, OT, Day Care/OPD, procedures, CMEs, hand-over, etc.

- - - - - - - - - -

- - - - - - - - - -

MODIFIED FLEXI WORKING HOURS7am-12pm 12pm-4pm 4pm-10pm 10pm-7am

5 hrs 3 hrs (-1 hr lunch) 6 hrs 9 hrs Table HO 1 hrs/day

mon MF2 (NORMAL + EVENING) 14tue MF1 8wed MF2 (NORMAL + EVENING) 14thu MF3 MF 3 (NIGHT) 17fri Post-night duty till 12pm OFF 5sat OFF 0sun MF 3 MF 3 (NIGHT) 14

Cumulative hours for week 72 Table HO 2

mon Post-night duty till 12pm OFF 5tue MF2 (NORMAL + EVENING) 14wed MF3 MF3 (NIGHT) 17thu Post-night duty till 12pm OFF 5fri MF2 (NORMAL + EVENING) 14sat MF3 MF3 NIGHT) 14sun OFF 0


mon MF 1 8tue MF3 MF3 (NIGHT) 17wed Post-night duty till 12pm OFF 5thu MF2(NORMAL + EVENING) 14fri MF3 MF3 (NIGHT) 17sat OFF 0sun MF2 (NORMAL + EVENING) 14


mon MF3 MF3 (NIGHT) 17tue Post-night duty till 12pm OFF 5wed MF1 8thu MF1 8fri MF1 8sat MF2 (NORMAL + EVENING) 14sun OFF 0

Cumulative hours for week 6023

Ensure compliance of respective Depts Allow flexibility according to the Framework

Gather input from various stake-holders within hospital for suggestion on further improvement

Medical Development Division will gather feedback in May/June 2014

Resolve relevant HO issues at hospital levelLiaises with JKN/BPP for more complicated issues

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NEW DISCIPLINES INTRODUCED

Since 2008 - Cabinet has decided to extend the Housemanship Training to 2 years 6 posting (5 compulsory, 1 obligatory) Emergency Medicine introduced as Alternative posting

2010 - Anaesthesia introduced as another Alternative posting to Emergency Medicine

2014 - 2 more Alternative posting introduced: Psychiatry Posting Primary Health

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To include Psychiatry HOD and FMS into the Jawatankuasa Latihan PPS at Hospital level

Only for hospitals offering these postings

Efficient posting of HOs to these 4 alternative postings

Give attention to relevant administrative aspects

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MEDICAL STUDENT

HOUSE OFFICER


SPECIALIST

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Medical Officer

Country requires more specialist & subspecialists in various fields

Current Master Programme not able to produce enough specialists to cater needs

IPTA only manage to train about 500 to 600 doctors into experts in a year

Brain drain – MOH trained specialists goes to private sector & universities

ISSUES & CHALLENGES

Limited trained capacities in local universitiesInadequate trained Health Human ResourcesLack of monitoring of trainees in Master programOn average 38% Master trainees graduated on timeParallel Pathways not well coordinateDichotomy of Post grad training

Promotion & Placement Bottle neck promotion for specialist grade UD54Placement of specialists to hospitals without adequate equipments

ISSUES & CHALLENGES

Maldistribution of Health Human ResourcesGeographical (Urban vs. Rural)Logistic constrainsLack of financial incentives

Attrition Brain drain of MOH specialists need attractive

retaining package High attrition of specialist at UD54

ISSUES & CHALLENGES

BIDANG ∑ PAKAR (2010) ∑ PAKAR (2013) KEPERLUAN (2020)

O&G 254 288 1149

ANAESTHESIA 326 384 1755

PEDIATRIK 278 369 1016

PERUBATAN DALAMAN 553 752 1984

PSIKIATRI 115 154 642

RADIOLOGI 183 243 931

PEMBEDAHAN AM 276 285 576

OFTALMOLOGI 179 217 920

ORTOPEDIK 219 249 566

OTORINOLARINGOLOGI 113 142 406

PATOLOGI 182 258 319

NUMBER OF SPECIALISTS in 2010 & 2013 vs.

PROJECTED COUNTRY’S NEEDS IN 2020

NUMBER OF SPECIALISTS PASSED FOR YEAR 2009-2013

Master Programme and Parallel Pathway

SPECIALTY QUALIFICATION 2013 2012 2011 2010 2009

INTERNAL MEDICINE

MRCP 44 76 67 55 30

MMED 24 25 31 27 34

PAEDIATRICMRCPCH 23 27 25 13 10

MMED 26 21 15 14 12

O&GMRCOG 5 5 5 3 3

MMED 37 19 23 26 15

ONCOLOGY FRCR 2 1 1 0 1

MMED 3 4 3 4 1

SURGERYFRCS 0 0 0 0 0

MMED 33 39 21 17 23

ANESTHESIAFANZCA 0 0 0 0 0

MMED 46 43 40 47 37

TOTAL 243 260 231 206 166

STRENGTHENING MO’s TRAINING:

Strengthening & facilitate parallel pathway (Membership Programme) in producing more specialist, e.g. in:MRCPMRCPCHMRCOGFANZCAFRCSEtc.

Establishment of Post Graduate Medical Education, Specialists & Subspecialists Unit under Medical Development Division of MOH

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Encouraged to take Part I / equivalent

Those who passed Part I / equivalent : Identify & Register them with hospital and Bahagian Perkembangan

Perubatan - parallel pathways registration form Must be posted to related department (e.g. those with MRCP part I/II

to Medical department) Facilitate M.O to complete their rotational posting:

MRCOG Antenatal ward, Labour room, Feto-maternal medicine, Uro-gynaecology, etc

MRCPRespiratory, Haematology, Endocrinology, Gastroenterology, Cardiology, etc

Register to Medical Development Division those who passed Part 2/PACES completely For gazettement and posting

BENEFIT OF REGISTRATION

Quality management, review & evaluation Equality, diversity & opportunity Delivery of appropriate curriculum &

assessment Support & development of trainees Management of education, training &

rotational posting Early gazettement

PARALLEL PATHWAYS

REGISTRATION FORM

MEDICAL STUDENT

HOUSE OFFICER


SPECIALIST

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Specialist: Master & Parallel Pathway

Need adequate number of generalist

Subspecialist training Merit for generalist who had served the periphery Requirement of rotation posting

Subspecialist encouraged to provide basic specialty services Except for specialized centers

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SPECIALIST VS SUBSPECIALIST

MEDICAL STUDENT

HOUSE OFFICER


SPECIALIST

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MANPOWER PLANNING - CONCLUSION

THANK YOU

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STRENGTHENING THE TRAINING OF HOs & MOs IN EFFORT TO PRODUCE MORE SPECIALISTS FOR THE COUNTRY: ROLE...

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