Clinical Quality & Safety

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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