Clinical Quality & Safety

Caring for your Eyes

Based on Malaysia National Eye Survey II 2014 report, cataract is the most common cause of blindness. The good news is this is preventable. SJMC’s highly experienced eye surgeons offer cataract surgery.

To measure the quality of cataract surgery, SJMC monitors the percentage of patients without ocular co-morbidity who obtained visual acuity of 6/12 or better within (≤) 3 months following cataract surgery.

Clinical Safety for Eye Care icon

SJMC’s clinical outcome for visual success is comparable to published literature from US, UK and Singapore and meets the target of 90% recommended in the Malaysian Hospital Accreditation Standards and Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS) Principles of Preferred Practice in Cataract Surgery 2017.

Percentage of patients without ocular co-morbidity obtained visual acuity of 6/12 or better within (≤) 3 months
following cataract surgery (A higher rate is better)

SJMC’s Clinical Outcome for Visual Success graph
Our rate for May 2021 to April 2022 Indicator Description Healthcare industry published rates
97% Percentage of patients without pre-existing ocular co-morbidity obtained visual acuity of 6/12 or better within (≤) 3 months following cataract surgery
>90%
Malaysian Society for Quality in Health Hospital Accreditation Standards and Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS) Principles of Preferred Practice in Cataract Surgery 2017

Hand Hygiene Indicators

We aim to minimise the risk of infection to patients, staff and visitors that come to our hospital.

What SJMC does to reduce your risk

SJMC has programmes in place to detect and prevent infections that are common within hospitals. Visitors to SJMC are encouraged through appropriate signages to use antiseptic hand rub located throughout the hospital.

What you can do to regduce your risk

There are several ways you can assist in preventing an infection:

  • Always wash your hands after using the toilet, bedpan or a commode
  • Wash or clean your hands before eating
  • Don’t be afraid to ask your doctor or staff caring for you, if they have washed their hands
  • Avoid touching your wound or devices (for example, fluid tubes into your arm or drain tubes)
  • Let the care staff know if your wound or areas around any of the lines or tubes become red or swollen or painful
  • Discourage visitors who may be feeling unwell
  • Stop smoking before any surgery, as smoking increases the risk of infection
Hand Hygiene Strategy & Audit icon

One of the most effective ways to prevent infection spreading amongst patients is for all health professionals to wash their hands. Hand hygiene is conducted in accordance with the ‘five moments’ that are: before touching a patient; before a procedure; after a procedure; after touching a patient; and after touching a patient’s environment.

SJMC participates in the WHO hand hygiene strategy, and hand hygiene audits are conducted regularly.

Hand hygiene compliance is reported as the percentage of correct moments from all observed moments.

Hand Hygiene compliance (A higher rate is better)

Hand Hygiene Compliance Graph
Our rate Indicator Description Healthcare industry published rates
Average for July 2022 to Jun 2023. 97%
Overall Hand Hygiene Compliance (a higher rate is better) Malaysia Patient Safety Goals target. 75%

Our Data & Results


  Quality Indicators Description SJMC Results
July to Dec 2022
Healthcare Industry Published Rates
Overall Hand Hygiene Compliance icon Overall Hand Hygiene Compliance (Higher score is better). 98% Malaysia Patient Safety Goals target: >75%
Knee prosthesis surgical site infections icon Knee prosthesis surgical site infections: Deep or organ / space SSI - hip prosthesis procedure (Lower score is better). 0% 0.56%
Hip prosthesis surgical site infections: Deep or organ / space SSI - knee prosthesis procedure (Lower score is better).

SJMC has a program in place to detect and prevent infections that are common within the hospital. Visitors to SJMC are encouraged through appropriate signage to use antiseptic hand rub located throughout our hospitals.

0% 0.33%
Inpatient falls icon Inpatient falls (Lower score is better). 0.041% 0.33%
Inpatient falls resulting in fracture or closed head injury (Lower score is better).

SJMC use a number of strategies to prevent falls and these include ensuring that call bells and personal items are within the patient’s reach and patients are assisted to the toilet at regular intervals. In addition, we have implemented patient alarms to minimize the risk of adult patients falling while admitted.

0% 0.01%
Serious Medication Errors icon Serious Medication Errors requiring intervention per 100 days of patient care (a lower rate is better).

Medicines are commonly used to treat a variety of conditions in the healthcare setting. SJMC has a robust medication safety system to ensure patient safety.

0% 0.005%
Congestive Heart Failure icon Congestive Heart Failure - prescribed ACEI /A2RA (Higher score is better) 95% 94.3%
Congestive Heart Failure - prescribed beta blocker (Higher score is better).

When patients are diagnosed with heart failure, several new medicines may be prescribed e.g. Angiotensin-converting enzyme (ACE) inhibitor (ACEI) and Beta Blockers. These medicines are proven to help you live longer, stay out of hospital and feel better.

100% 87.9%
Percutaneous Transluminal Coronary Angioplasty (PTCA) - vessels where primary success achieved (Higher score is better).

PTCA is a procedure used to increase the flow of blood through a narrowed blood vessels (artery) in the heart.

100% 96.4%
Staging Annotation for Current Radiation Therapy Course icon Staging annotation for current radiation therapy course (Higher score is better).

We ensure accurate documentation of staging information, which is crucial for better patient selection onto treatment pathways and communication among care providers.

88% 69.4%
Contrast Extravasation icon Contrast extravasation during an IV contrast enhanced CT procedure (Lower score is better).

We monitor contrast dye administration to ensure minimal contrast dye leakage from the blood vessel into the surrounding tissues.

0.017% 0.19%
CTDIvol for Non-contrast CT Head Examinations icon CTDIvol for non-contrast CT head examinations (Lower score is better).

We aim to minimise radiation dose in individual radiology studies as an effective method of reducing patient radiation exposure and is in keeping with the "As Low As Reasonably Achievable (ALARA)" principle.

0.793% 7.02%
  1. SJMC participates in the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program and use their definitions for these indicators. This program provides a national clinical benchmarking service and is comprised of comparative information on the processes and outcomes of health care.
  2. Australian Council on Healthcare Standards (ACHS). Australasian Clinical Indicator Report: 2013–2021: 23rd Edition. Sydney, Australia; ACHS; 2023.
  3. https://www.healthdirect.gov.au/angioplasty
  4. https://www.health.qld.gov.au/__data/assets/pdf_file/0030/993009/Medications-booklet-web-version.pdf

Layperson Summary of research

 

1) Left main stem stenosis angioplasty with intravascular ultrasound optimisation criteria guidance using a new generation everolimus drug-eluting stent

This research studied the effectiveness of a new generation of stent (Synergy Megatron DES) in treating blockages in a major heart artery called the left main stem (LMS). To ensure the best outcomes, our cardiologists also incorporated an imaging technique called intravascular ultrasound (IVUS) during the procedure.

All eight patients who received the stent had successful procedures with minimal blockage (<30%) remaining. None of them experienced any major heart-related complications in the hospital or within the first 30 days after the procedure.

It was found that the stent was successful in meeting specific criteria such as making sure the stent fits well, expands optimally, lands in the appropriate zone, and avoids certain complications. Optimal expansion of the stent successfully occurred in 87.5% of cases, widening the inner space of the artery and improving blood flow. 

In summary, combination of the new generation stent and IVUS-guided optimization appears to be a beneficial approach in treating significant blockages in the left main stem artery.

2) Intravascular imaging-guided treatment of severe coronary artery calcification with orbital atherectomy: A prospective single-centre registry

When the cardiac arteries get hard due to calcium buildup, it can make regular angioplasty less effective. This study looked at a method called orbital atherectomy (OA) to treat these calcified arteries, evaluating its in-hospital safety and efficacy. OA is a method which smoothens out calcified blockages by using a sanding technique.

This study looked at a group of ten patients who underwent this procedure and followed them up for a period of time. It was found that OA was performed safely and relatively easily with successful stent delivery in all cases, with a low rate of immediate complications (only 10% of cases experienced dissection (tear in the vessel wall). 

None of the patients experienced major heart-related complications while in the hospital or in the 30 days after.

It was found that that using special imaging techniques such as OCT or IVUS, careful selection of patients suitable for undergoing OA, and monitoring for complications during the procedure helped prevent complications.

In summary, OA has an important role in preparing the calcified areas before putting in a stent. It helps makes sure the stent fits well and expands adequately. The procedure is safe, works well, and has very few problems.