Hospital Accreditation

What is Hospital Accreditation Programme?

The MSQH Hospital Accreditation Program (HAP) is a voluntary, independent programme supported and administered by healthcare professionals; organised under the auspices of the Malaysian Society for Quality in Health (MSQH), a not-for-profit and non- governmental society formed subsequent to a tripartite Memorandum of Understanding between the Malaysian Ministry of Health (MOH), Malaysian Medical Association (MMA) and Association of Private Hospitals, Malaysia (APHM).

6th Edition Standards

Hospital Survey Guidelines

Hospital Survey Application Form

Accredited Hospitals

Performance Indicators

Standard Development

What is Hospital Accreditation Programme?

A self-assessment and external peer review process used by healthcare organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system.

Performance measurement requires a reference standard. Therefore to measure the safety and quality of patient care, standards are required against which healthcare facilities can be compared.

The development of the MSQH Hospital Accreditation Standards is an evolutionary process, the standards are periodically reviewed and updated in light of advances in healthcare and currently accepted practices as well as regulatory requirements. MSQH standards are developed and edited in cooperation with professionals from public and private healthcare providers and consumers. Malaysian Hospital Accreditation Standards are grouped into six (6) major areas of concern. These areas of concern are:

Organisation and Management

Human Resource Development
& Management

Policies and Procedures

Facilities and Equipment

Safety & Performance Improvement Activities

Special Requirements

Special requirements of these standards are the safety aspects that are not compromised. An organization that does not meet the safety requirements of the standards will not be accredited although it has met the rest of the standards. These standards provide the basis for organisational assessment of the delivery of safety and quality patient care and services, and the utilisation of available resources.

These standards are applicable to all types of hospitals – public and private, large and small, urban and rural. Today, many people are concerned about finding the best ways to meet their healthcare needs. When you use a facility accredited by the MSQH, you know it meets our rigorous standards.

The MSQH may accredit any healthcare facility or service as defined by the Private Healthcare Facilities and Services Act 1998, which defines healthcare facility as any premises in which one or more member of the public receive healthcare services. Similar healthcare services in the public sector are also eligible to be surveyed and accredited:

Healthcare facilities applying for first-time accreditation must attend mandatory training and education conducted by MSQH trainers.

An official request letter must be submitted to MSQH for the training.

Successful applicants will be notified in writing about the processes they must undergo, including training and self-assessment before the survey.

Apply online for the Hospital Accreditation Survey.

The completed application must reach MSQH at least six (6) months before the intended survey date for logistical planning.

Private Healthcare Facilities must attach a valid hospital license from the Ministry of Health. Only services listed in the license will be surveyed.

Applications are valid for 12 months from the submission date.

Survey dates will be arranged through mutual consultation, and MSQH will assign a survey team appropriate to the facility’s complexity, with facility agreement.

The minimum time frame required for any Healthcare Facility to be eligible for the survey is six months post-training to allow time for the facility to make adequate preparation. The facility is required to send a request letter for training.

MSQH will inform facilities about the costs related to preparation and the survey itself.

MSQH will send the renewal application form six (6) months before the current accreditation expires.

Facilities in their second or subsequent surveys are expected to demonstrate improved quality of care and services.

The survey date will be confirmed in writing by MSQH.

For your Customer

Tested performance standards that focus on quality and safety in patient care,
Assurance that your service meets or exceeds the quality health standards available in Malaysia and is recognised internationally,
Strengthening community trust in being certified is evidence to patients and community that your organisation is committed to providing Safe and Quality Healthcare Service,
Greater client satisfaction,
Trust in your staff's ability to respond appropriately to patient needs and to protect their rights,
Security in the knowledge that quality systems are in place to identify and remedy health problems.

For your Facility

Comprehensive and structured analysis of performance,
A broad based improvement in delivery of services,
Reduced re-work and rectifications, since things are done right the first time and every time,
Establishes organisational credibility, builds up staff and stakeholders’ confidence towards the hospital,
Better outcomes of care,
Reduced risk and medical defence costs,
Confidence that you focus on safety, quality care and service excellence,
Enhanced public trust, image and competitive edge.

For People Who Working in your Facility

A valuable learning experience through self-assessment, reflection, and challenge to tradition,
Empowerment to improve the processes and change current practices in delivery of care,
Enhanced teamwork, staff satisfaction, staff morale and confidence in the services that they deliver,
Provision with the right tools and new techniques and technology for safe and quality services in a low risk environment,
Being part of a client-focused team to achieve service excellence,
Equipping with a rigorous approach to continuous improvement,
Sharing knowledge through a nationwide network of quality health providers,
Esteem and endorsement by peers and the public for a conscious and active effort in maintaining high professional standards.

For People Who Fund your Medical Clinic

Confidence that your organisation is client focused,
Assurance that your organisation operates according to industry standards and meets international safety standards and requirements,
Success and sustainability of business through safer quality outcomes,
Confidence that risk is minimised and managed to create better shareholder value.

Four Year Accreditation

A Four-Year Accreditation is awarded to those facilities, which in the opinion of MSQH, substantially comply with the MSQH healthcare standards. It should be noted that the healthcare facilities must achieve substantial compliance in all Core Standards and other Safety Standards, to achieve Four-Year Accreditation.

Delayed Accreditation

A one-year Accreditation is awarded to those facilities which have met the requirements of most of the standards but have some safety issues which need to be addressed. A facility awarded a one-year accreditation is offered the opportunity to undergo Focus Survey within the next twelve (12) months

Non-Accreditation

Non Accreditation will be awarded to a facility in which the surveyors have observed and reported that a significant number of standards are not complied with. Facilities that are not accredited are encouraged to implement the recommendations made in the Survey Report and to re-apply for survey. It is recommended that a minimum of twelve (12) months should elapse, to allow time for remedial actions and rectification works, before the next survey is undertaken.