SHORTFALL IN QUALITY REPORT FORMSIQF.CPSU ver.

2023

FACILITY HOSPITAL SULTAN IDRIS SHAH SERDANG

(Dept./ Hosp./ Institution/ JKN/ Division/ JKN SELANGOR
Program)
KPI: (Please  the option. If PPTPA/OTHERS, please write down the officer’s name & designation)
√ CLINICAL SERVICE  HPIA  PPTPA Name :
Designation :
 OTHERS

YEAR:
PERIOD OF PERFORMANCE: (Please  the option)
√ JAN – JUN  JUL – DEC √ JAN – DEC  OTHERS: Please specify: 2 0 2 3

4.4 PERATUS PENOLONG PEGAWAI PERUBATAN

DENGAN KELAYAKAN POST BASIC ATAU LATIHAN
INDICATOR STANDARD ≥ 80%
LANJUTAN DITEMPATKAN MENGIKUT BIDANG
PENGKHUSUSAN

PERFORMANCE 70.13 %
NUMERATOR 54 DENOMINATOR 77
ACHIEVED

INVESTIGATION TEAM
Name Designation
Team Leader/ Coordinator
Hj. Muhammad Azharuddin Bin Ab Ghani Ketua Penyelia Pen.Pegawai Perubatan U42
Team Members

PPP Siti Rohani Bt Abdul Razak Penolong Pegawai Perubatan U29

PPP Mawarni bt Ibrahim Penolong Pegawai Perubatan U32

BACKGROUND SUMMARY OF SIQ

1. Penolong Pegawai Perubatan yang bertugas di jabatan yang telah ditempatkan, boleh mengambil Post
Basic selepas berkhidmat selama minimum 6 bulan di jabatan tersebut.
2. Ketua jabatan / penyelia jabatan akan menyarankan pegawai untuk mengambil Post Basic mengikut bidang
pengkhususan jabatan setelah 6 bulan atau lebih bertugas di jabatan tersebut.
3. Terdapat 2 faktor utama yang menyebabkan terjadinya SIQ ini iaitu kenaikan pangkat dan berlaku
pertukaran pindah masuk atau pertukaran secara dalaman.
4. PPP gred U29 yang telah mengambil Post Basik apabila telah dinaikkan pangkat ke U32 dan ke atas akan
bertukar keluar hospital atau bertukar ke jabatan lain bagi mengisi kekosongan jawatan di jabatan yang
diperlukan seperti PPP di Jabatan Urologi telah mempunyai Post Basik Urologi berpindah ke MOPD kerana
kenaikan pangkat.
5. Selain itu, terdapat juga PPP yang bertukar masuk dari fasiliti lain atau bertukar secara dalaman dan
pg. 1/4
 SHORTFALL IN QUALITY REPORT FORMSIQF.CPSU ver. 2023

ditempatkan ke jabatan lain bagi mengisi kekosongan jawatan demi kepentingan perkhidmatan di jabatan
CONTRIBUTING FACTORS THAT LEAD TO THE SIQ:
Please choose and tick ALL relevant contributing factors/ root cause(s) & DESCRIBE the factors at the
description space.
A INDIVIDUAL STAFF FACTOR √ DESCRIPTION
A1 Lack of knowledge/experience/ skill A8 -1. Pegawai yang telah cukup tempoh
A2 Distraction berkhidmat 13 tahun perlu mengisi borang kenaikan
A3 Fatigue/ stress pangkat dan perlu berpindah ke jabatan lain untuk
A4 Lapse of concentration mengisi kekosongan jawatan di jabatan.
A5 Non-compliance to protocol/ policy/ SOP
A8-2. – Pegawai telah berpindah ke jabatan yang
A6 Personal issue
baru tetapi tidak mengambil Post Basik
A7 Unsafe behaviour – assuming, not asking clarification etc. pengkhususan jabatan ( belum mencapai 6 bulan di
Others: specify: kenaikan pangkat , Pegawai tidak mengambil √ jabatan tersebut )
A8
Post Basik setelah bertugas di jabatan selepas 6 bulan bertugas

B TEAM FACTOR √ DESCRIPTION

B1 Written communication issue
B2 Verbal communication issue
B3 Unclear roles and responsibility
B4 Lack of supervision/ monitoring
B5 Ineffective leadership & responsibility
B6 Problem in seeking help
B7 Staff or colleague response/ support to help
B8 Others: specify:

TASK & TECHNOLOGY FACTOR √ DESCRIPTION

C Protocols/ S.O.P/ guidelines issues (availability/ accuracy/ etc.)
1
C Health information issues (availability/ accuracy/ etc.)
2
C Task design issue
3
C Information technology (e.g., malfunction, system design) problem
4
C Decision making aids problem
5
C Medication related issue (e.g., wrong prescription, similar
6 packaging/ sounding names, complicated dosage design)
C Radiotherapy related issue (e.g., miscalculation of dose)
7
C Others: specify:
8

D WORK & ENVIRONMENTAL FACTOR √ DESCRIPTION

D1 Building & design related issues
D2
Physical environment issue(temperature, lighting, wet floor, Pegawai yang berpindah masuk dari luar atau
holes, storage, housekeeping)
bertukar secara dalaman perlu ditempatkan di
D3 Noisy, busy surrounding
Malfunction/ failure of equipment/ maintenance of equipment,
jabatan lain bagi mengisi kekosongan jawatan
D4 di jabatan tersebut tetapi tidak mengikut Post
functionality, design
D5 Cluttered surrounding Basik yang telah dimiliki.
D6 Unsafe surrounding
D7 Inappropriate allocation of staff (i.e., not according to workload/ √
specialty)
pg. 2/4
 SHORTFALL IN QUALITY REPORT FORMSIQF.CPSU ver. 2023

D8 Heavy workload, inadequate break

D9 Service delivery- delay, missed, inappropriate
D1
Others (specify):
0

E MANAGEMENT & ORGANIZATIONAL FACTOR √ DESCRIPTION

E Leadership and governance issue
1
E Pegawai ditempatkan di jabatan lain ( selain dari
Organizational structure issue
2
E Post Basik penkhususan sedia ada) kerana
Objectives, policies and standard issue
3
E Resources constraints (human/ financial) √ kekurangan PPP di jabatan tersebut disamping
4
E
untuk keperluan perkhidmatan di jabatan.
Inadequate safety culture/ lack priorities in safety
5
E
Others (specify):
6

F PATIENT/ CUSTOMER FACTOR √ DESCRIPTION

F1 Miscommunication between patient/ customer and staff
F2 Language barrier
F3 Non-compliance patient/ customer
F4 Social issue
F5 Patient/ customer-staff relationship issue
F6 Patient-patient/ customer-customer relationship issue
F7 Complexity of clinical condition
F8 Pre-existing comorbid
F9 Known risk associated with treatment
F10 Others (specify):

G EXTERNAL FACTOR e.g political issue, disaster, etc. √ DESCRIPTION

Please specify:

ACTION PLAN TABLE

Based on the contributing factors(s) listed above, identify the most effective action plan(s).

Person responsible Expected Completion

No. Contributing Factors Description of Action Plan
(Name & designation) Date

Mengekalkan jawatan hakiki pegawai

Hj. Muhammad
1 Kenaikan pangkat sebagai jawatan fleksi agar pegawai Telah dilaksanakan
Azharuddin
dapat kekal bertugas di jabatan

Menyarankan pegawai yang telah

Pertukaran pindah
mempunyai Pos Basik tidak Hj. Muhammad
2 masuk dan pertukaran Telah dilaksanakan
digalakkan untuk berpindah keluar Azharuddin
dalaman
dari jabatan

pg. 3/4
 SHORTFALL IN QUALITY REPORT FORMSIQF.CPSU ver. 2023

INVESTIGATION TEAM
TEAM LEADER/ COORDINATOR HEAD OF DEPARTMENT/ UNIT

(Name/ Signature/ Designation/ Date/ Stamp) (Name/ Signature/ Designation/ Date/ Stamp)

HOSPITAL/ INSTITUTION/ JKN/ PROGRAM

QUALITY OFFICER DIRECTOR

(Name/ Signature/ Designation/ Date/ Stamp) (Name/ Signature/ Designation/ Date/ Stamp)

SIQ ANALYSIS VERIFICATION & ACKNOWLEDGEMENT:

pg. 4/4
pg. 5/4
pg. 6/4