PI-01-019 7th Ed. New Healthcare Workforce Mental Health and Psychological Wellbeing Assessment Rate Human Resources & Governance • 1.2.7.1
80% Awaiting Reading Zero Readings
— E1 E2 E3 E4
Pn. Aishah Kamal
PI-06-003 Central Line-Associated Bloodstream Infection (CLABSI) Rate Infection Control • 6.1.7
1.2 per 1,000 line days 3.6 breach
E1 E2 E3 E4
Dr. Tan Mei Ling
PI-23A-001 Mortuary Deceased Dual-Identification and Chain of Custody Verification Compliance Mortuary Services • 23A.1.1
100% 99.1% breach
E1 E2 E3 E4
Pn. Harlina binti Mansor
PI-06-002 Catheter-Associated Urinary Tract Infection (CAUTI) Rate Infection Control • 6.1.7
1.8 per 1,000 catheter days 0.2 target
E1 E2 E3 E4
Dr. Tan Mei Ling
PI-05-001 Adult Inpatient Medication Reconciliation Completion Rate Within 24 Hours Medication Safety • 18.2.5
90% 94.6% target
E1 E2 E3 E4
Pn. Rohani binti Ismail
PI-01-007 Hospital-wide Direct Observation Hand Hygiene Compliance Rate Infection Control • 6.1.4
85% 88% target
E1 E2 E3 E4
Dr. Tan Mei Ling
PI-02-001 Hospital Fire Evacuation Drill Execution and Response Compliance Facility & Environmental Safety • 2.2.1
90% 95.1% target
E1 E2 E3 E4
En. Mohd Zaki Ariffin
PI-04-001 Critical Life-Support Biomedical Equipment Planned Preventive Maintenance (PPM) Rate Biomedical Engineering • 4.1.3
95% 97.9% target
E1 E2 E3 E4
En. Hakim Osman
PI-06-001 Surgical Site Infection (SSI) Rate for Clean and Clean-Contaminated Surgery Infection Control • 6.1.7
1.5% 1.1% target
E1 E2 E3 E4
Dr. Tan Mei Ling
PI-06-014 Inpatient Fall Rate with Injury per 1,000 Patient Bed Days Nursing & Patient Safety • 5.3.1
2 per 1,000 bed days 0.2 target
E1 E2 E3 E4
Matron Norliah binti Hashim
PI-07-001 Elective Surgical Informed Consent Documentation Audit Compliance Patient Rights & Ethics • 7.1.1
95% 97.9% target
E1 E2 E3 E4
Pn. Rohani binti Ismail
PI-08-001 Inpatient Discharge Summary Completion Rate Within 48 Hours Medical Records • 8.2.1,8.6.1
95% 98.9% target
E1 E2 E3 E4
Pn. Mastura binti Ahmad
PI-09A-001 Acute Myocardial Infarction Door-to-ECG Time Compliance Within 10 Minutes General Medicine • 09A.1.1
90% 94% target
E1 E2 E3 E4
Dr. Azmi Razak
PI-09B-001 Unplanned Return to Operating Theatre Within 48 Hours General Surgery • 09B.1.1
1% 1.2% alert
E1 E2 E3 E4
Dr. Azmi Razak
PI-09C-001 Primary Emergency Caesarean Section Decision-to-Delivery Time (Category 1) Within 30 Minutes Obstetrics & Gynaecology • 09C.1.1
85% 90.6% target
E1 E2 E3 E4
Dr. Azmi Razak
PI-09D-001 Paediatric Inpatient Unplanned Readmission Rate Within 30 Days Paediatrics • 09D.1.1
3.5% 3.2% target
E1 E2 E3 E4
Dr. Wong Wei Jun
PI-09E-001 Elderly Hip Fracture Surgery Initiation Within 48 Hours of Admission Orthopaedics • 09E.1.1
80% 85.2% target
E1 E2 E3 E4
Dr. Azmi Razak
PI-09F-001 Post-Anaesthetic Care Unit (PACU) Hypothermia Rate (Core Temperature < 36.0°C) Anaesthesia • 09F.1.1
5% 2.7% target
E1 E2 E3 E4
Dr. Lim Chee Keong
PI-10-001 WHO Surgical Safety Checklist 3-Phase Compliance Rate Surgical Safety • 10.1.1
98% 99% target
E1 E2 E3 E4
Dr. Lim Chee Keong
PI-11-001 Ambulatory Day Care Surgery Same-Day Discharge Readiness Rate Ambulatory Care • 11.1.1
95% 98.8% target
E1 E2 E3 E4
Dr. Azmi Razak
PI-12A-001 Intensive Care Unit (ICU) Unplanned Readmission Rate Within 48 Hours Critical Care • 12A.1.1
3% 2.8% target
E1 E2 E3 E4
Pn. Faridah binti Kassim
PI-13-001 Third- and Fourth-Degree Perineal Tear Rate in Vaginal Deliveries Labour Delivery • 13.1.1
2.5% 1.9% target
E1 E2 E3 E4
Matron Norliah binti Hashim
PI-14-001 Emergency Department Door-to-Doctor Time Compliance for Triage Red & Amber Emergency Care • 14.1.1
95% 98.8% target
E1 E2 E3 E4
Dr. Nurul Huda
PI-15-001 Inpatient Therapeutic Diet Order Verification and Delivery Accuracy Rate Dietary Services • 15.1.1
98% 99% target
E1 E2 E3 E4
En. Khairul Anuar
PI-16-001 Central Sterile Supply Department (CSSD) Autoclave Biological Indicator Pass Rate Sterilisation & CSSD • 16.2.1
100% 99.1% alert
E1 E2 E3 E4
Pn. Zainab binti Sulaiman
PI-17A-001 Post-Operative Orthopaedic Major Joint Mobilization Initiation Within 24 Hours Rehabilitation Services • 17A.1.1
90% 92.8% target
E1 E2 E3 E4
En. Fauzi bin Ramli
PI-18-001 Medication Administration Error Rate with Harm per 10,000 Occupied Bed Days Pharmacy & Medication • 18.1.1,18.3.1
0.5 per 10,000 bed days 0 target
E1 E2 E3 E4
Dr. Suresh Nair
PI-19-001 Diagnostic Imaging Critical Findings Communication Compliance Within 30 Minutes Diagnostic Imaging • 19.2.1
95% 99% target
E1 E2 E3 E4
En. Shahril bin Hassan
PI-19-002 Radiation Protection Apparel Annual Fluoroscopic Integrity Inspection Compliance Radiation Safety • 19.1.1
100% 100% target
E1 E2 E3 E4
En. Shahril bin Hassan
PI-20-001 Clinical Pathology Panic Critical Laboratory Value Communication Within 15 Minutes Laboratory Services • 20.1.1
98% 98.9% target
E1 E2 E3 E4
Pn. Salmiah Zakaria
PI-21-001 Hospital Laundry Thermal Disinfection Wash Cycle Validation Adherence Rate Linen & Support • 21.1.1
100% 99% alert
E1 E2 E3 E4
Pn. Harlina binti Mansor
PI-22-001 7th Ed. New Environmental Surface Cleanliness ATP Bioluminescence Swab Compliance Rate Housekeeping & Hygiene • 22.1.1,6.1.13.1
90% 92.5% target
E1 E2 E3 E4
Pn. Harlina binti Mansor
PI-24-001 Hospital Security CCTV Coverage and Perimeter Patrol Verification Rate General Administration & Security • 24.1.1
95% 98.9% target
E1 E2 E3 E4
Pn. Rohani binti Ismail
PI-25-001 Blood Product Bedside Dual-Verification and Transfusion Monitoring Compliance Blood Transfusion Safety • 25.1.1
100% 98.9% alert
E1 E2 E3 E4
Pn. Salmiah Zakaria
