Malaysian Hospital Accreditation Standards 4th Edition January 2013

SERVICE STANDARD 12 Ambulatory Care Services

TOPIC 12.1: ORGANISATION AND MANAGEMENT

STANDARD 12.1.1

The Ambulatory Care Services are organised to provide safe and efficient care for ambulatory patients. The
Ambulatory Care Services are coordinated with other departments and services of the Facility. There is a
policy to specify which patients can be treated, which procedures and under what form of
anaesthesia/sedation can be performed as ambulatory care. The service could also include patients treated
and managed in the day care for medical conditions, diagnostic and interventional procedures, such as the
endoscopic services. Patients for chemotherapy if included in this service should be treated in a separate area
of its own segregated from other areas.

CRITERIA FOR COMPLIANCE:

12.1.1.1 There are documented purposes which may be termed Vision and Mission statements, goals,
objectives and values that suit the scope of the Ambulatory Care Services. When compiling the
purposes, consideration shall be given to the following:

a) They are what the services want to achieve.

b) The goals of the service are achieved by the objectives as stated.

c) The goals and objectives are consistent with professional standards, guidelines and
relevant legislation.

d) Statements are monitored, reviewed and revised as required accordingly.

12.1.1.2 There is an organisation chart which:

a) provides a clear representation of the structure, function and reporting relationships

between the Head and the staff of the Ambulatory Care Services;

b) is accessible to all staff;

c) includes off-site services if applicable;

d) is revised when there is a major change in any one of the following:

 organisation;
 functions;
 reporting relationships;
 goals and objectives;
 staffing patterns.

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12.1.1.3 There are written and dated specific job descriptions for all categories of staff that include:

a) qualifications, training, experience and certification required for the position;

b) lines of authority;

c) accountability, functions and responsibilities;

d) review when required and when there is a major change in one of the following:

 nature and scope of work;

 duties and responsibilities;
 general and specific accountabilities;
 qualifications required and privileges granted;
 staffing patterns;
 Statutory Regulations.

12.1.1.4 Regular staff meetings which include medical practitioners are held to discuss issues and
matters pertaining to the operations of the Ambulatory Care Services. Minutes are kept and
accessible to relevant staff.

12.1.1.5 Personnel records on training, staff development, leave and others are maintained for every
staff.

12.1.1.6 The Head of the Ambulatory Care Services is involved in the planning, management, and
justification of the budget and resource utilisation of the services.

12.1.1.7 The Head of the Ambulatory Care Services is involved in the appointment and/OR assignment of
staff.

12.1.1.8 The Ambulatory Care Services is represented on the Operating Theatre Committee where this is
appropriate.

12.1.1.9 The Head of the Ambulatory Care Services shall ensure that the staff of Ambulatory Care
Services complete incident reports which are discussed by the services with learning objectives
and forwarded to the Person In Charge (PIC) of the Facility.

12.1.1.10 Incidents reported have had Root Cause Analysis done and action taken to prevent recurrence.

12.1.1.11 Where required by the size and magnitude of the services, ancillary staff including clerical and
maintenance personnel, are available to support the work of the professional staff.

12.1.1.12 Ambulatory Care Services are provided appropriate to the Facility’s scope of medical and
surgical services.

12.1.1.13 Appropriate statistics and records shall be maintained in relation to the provision of Ambulatory
Care Services and used for managing the services and patient care purposes.
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12.1.1.14 The records maintained by the Ambulatory Care Services are adequate for clinical, medicolegal,
and evaluation purposes and include the following:

a) A record of medical practitioners conferred the privileges of performing specific procedures

is displayed, available and accessible to all staff.

b) A register of operations/procedures performed within the Ambulatory Care Services is

maintained.

c) A record of the procedure performed is filed in the patient’s medical record. Each record
contains details of the anaesthetic procedure and personnel involved, the name and
designation of the person who performed the procedure, findings, the dressings applied
and drainage systems inserted and the postoperative orders, discharge and follow up
notes.

d) Standard drug administration records are maintained and regulations relating to the control
of drugs are followed.

e) Documented evidence of the counting of accountable items used in operating theatre and
a copy of this is included in the patient’s medical record.

12.1.1.15 Clinical staff performs within the privileges conferred.

12.1.1.16 Support services such as pharmacy, radiology, pathology and blood bank are available as
appropriate, and effective communication and relationship with these services are maintained.

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TOPIC 12.2: HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

STANDARD 12.2.1

The Ambulatory Care Services are directed and staffed to achieve the objectives of the services. Staff of the
services have access to appropriate education programmes to maintain and augment their knowledge and
skills.

CRITERIA FOR COMPLIANCE:

12.2.1.1 The direction by the Head and staffing of the services are provided by individuals qualified by
education, training, experience and certification to meet the demands of the various positions
and to achieve the objectives of the services.

12.2.1.2 The authority, responsibilities and accountabilities of the Head of Ambulatory Care Services are
clearly delineated and documented in a letter of appointment.

12.2.1.3 Sufficient numbers of personnel and support staff with appropriate qualifications are employed to
enable the services to meet the documented purposes.

12.2.1.4 There is a structured orientation programme where new staff including medical practitioners are
briefed on their services, operational policies and relevant aspects of the Facility to prepare them
for their roles and responsibilities.

12.2.1.5 There is evidence of a staff development plan which provides the knowledge and skills required
for staff to maintain competency in their current positions as the demands of positions evolve.

12.2.1.6 There are continuing education activities for staff including medical practitioners to pursue
professional interests and to prepare for current and future changes in practice. There is
evidence that staff education and development needs have been appraised and identified.

12.2.1.7 Professional staff are actively assisted to attend relevant programmes conducted by their
professional groups, other related associations, and educational institutions. Where the Facility
cannot provide the necessary programme, cooperation is sought from external sources.

12.2.1.8 Staff including medical practitioners receive written evaluation of their performance at the
completion of the probationary period and annually thereafter, or as defined by the Facility.

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TOPIC 12.3: POLICIES AND PROCEDURES

STANDARD 12.3.1

Documented policies and procedures shall reflect current knowledge and practice for the Ambulatory Care
Services, and they are consistent with statutory requirements and the objectives of the services.

CRITERIA FOR COMPLIANCE:

12.3.1.1 There are written policies and procedures and a list of approved procedures for the Ambulatory
Care Services, and they are consistent with the overall policies of the Facility.

12.3.1.2 Policies and procedures are developed in collaboration with staff, medical practitioners,
Management and where required with other external service providers and with reference to
relevant sources involved.

12.3.1.3 Policies and procedures are dated, authorised, signed and reviewed at least once every three
years and revised as required.

12.3.1.4 New and revised policies and procedures are communicated to all staff.

12.3.1.5 There is evidence of compliance with policies and procedures.

12.3.1.6 Copies of policies and procedures, relevant Acts, Regulations, By-Laws and statutory
requirements are accessible to staff.

12.3.1.7 There is evidence of a planned systematic approach to the provision of patient care. This
includes:

a) available criteria for selection and assessment of cases;

b) policy on use of sedation during procedures;

c) documentation of the admission policies including age or disease limitations and the
restrictions concerning the scope of clinical services offered;

d) the booking and admission of patients comply with these admission policies;

e) essential information is given to all patients which outlines:

i) the patient’s pre-admission responsibilities and preparation;

ii) the functioning of the Ambulatory Care Services;
iii) type of anaesthesia and postanaesthetic effects;
iv) provision for after-hours contact and emergency care;
v) the patient’s post-discharge responsibilities.

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f) the requirements for a preanaesthetic assessment to be performed by a medical

practitioner;

g) patient identification, with the nature and site of the procedure marked and verified by the
surgeon and the consent documents checked;

h) observations of the patient’s pre-, intra- ,and post-procedure status and vital signs are
monitored and recorded in the medical record;

i) a dedicated anaesthetist is present or readily contactable until all patients who have
undergone anaesthesia/sedation are discharged;

j) the discharge procedure ensures the patient is given relevant documented postoperative
instructions and there is a responsible person accompanying the discharged patient. The
address and phone number of the discharge custodian is recorded in the medical record.

12.3.1.8 The policies and procedures for management of emergency patients shall include arrangement
for transfer of patients, where necessary.

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TOPIC 12.4: FACILITIES AND EQUIPMENT

STANDARD 12.4.1

There are adequate physical facilities and equipment for the safe and efficient functioning of the Ambulatory
Care Services. The services may operate from a purpose-built facility, designated rooms such as those used
for oncological purposes or from the main Operating Suite Services.

CRITERIA FOR COMPLIANCE:

12.4.1.1 Facilities for Ambulatory Care Services shall include:

a) storage space for equipment, surgical supplies, linen, housekeeping equipment, and
pharmaceutical supplies, including the storage of dangerous and psychotropic drugs;

b) easy access for disabled persons;

c) vehicle access to facilitate the safe admission and discharge of patients;

d) doorways, corridors, ramps, and stairwells are kept free of obstruction and are wide
enough for the evacuation of non-ambulatory patients;

e) suitable lighting;

f) adequate medical gas and suction supplies;

g) adequate provision for emergency power and uninterrupted power supply (UPS) where
indicated.

12.4.1.2 The Ambulatory Care Services shall comply with all safety features in accordance with regulatory
requirements which include:

a) Wiring installation conforms to Malaysian Standards for cardiac-protected or body-

protected electrical areas where required.

b) Electrical equipment complies with relevant electrical standards on the safe use of
electricity in patient care.

c) Staff are aware of the appropriate procedures in the safe use and application of
electromedical equipment.

d) Regular maintenance and monitoring of facilities and equipment, and a system to respond
to breakdown repair and replacement.

e) Emergency biomedical equipment, e.g. defibrillator is checked at least once a week or

after each use and the result is recorded.

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12.4.1.3 Equipment required for Ambulatory Care Services includes:

a) resuscitation trolleys;

b) fire extinguishers at relevant areas;

c) proper sterilisation facilities.

Notes/Explanation

Proper sterilisation facilities refer to equipment for disinfection of endoscope, etc.

12.4.1.4 Where specialised equipment is provided by the attending medical practitioner, such equipment
must have the prior approval by the Person In Charge (PIC) of the Facility and should be
checked to comply with the relevant safety requirements and be appropriately sterilised before
use.

12.4.1.5 There is documented evidence that equipment complies with relevant standards, e.g. those set
by SIRIM Berhad (Standards and Industrial Research Institute of Malaysia) and current statutory
requirements.

12.4.1.6 There is evidence that the facility has a comprehensive maintenance programme such as
predictive maintenance, planned preventive maintenance and calibration activities, to ensure the
facilities and equipment are in good working order.

12.4.1.7 Where specialised equipment is used, there is evidence that only staff who are qualified and
privileged by the Facility operate such equipment.

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TOPIC 12.5: SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

STANDARD 12.5.1

The Head of the Ambulatory Care Services shall ensure the provision of quality performance with staff
involvement in the continuous safety and quality improvement activities of the Services.

CRITERIA FOR COMPLIANCE:

12.5.1.1 There is evidence that the Head of the Service has in a written document assigned
responsibilities to appropriate individuals/committees for safety and quality improvement
activities within the services.

12.5.1.2 There are planned and systematic safety and quality improvement activities that monitor and
evaluate the performance of the services including a plan for action and follow up to ensure that
the action taken is effective in continually improving the quality of care. Innovation is advocated.

12.5.1.3 There are safety and quality improvement activities in place which support the Facility’s safety
and quality improvement activities including tracking and trending of specific performance
indicators not limited to but at least two (2) of the following:

a) unplanned admissions of ambulatory care patients as inpatients. (sentinel event)

b) cancellation rate of ambulatory care cases

Notes/Explanations

Reports are available on indicators include tracking and trending for specific performance
indicators carried out.

12.5.1.4 Feedback on results of safety and quality improvement activities are regularly communicated to
the staff.

12.5.1.5 Appropriate documentation of safety and quality improvement activities is kept and confidentiality
of staff and patients is preserved.

12.5.1.6 There are safety and quality improvement activities that address staff safety.

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