MSQH-Surv 05
Issue 6/2014
Page 1
APPLICATION FOR SURVEY
The undersigned hereby applies for an Accreditation Survey by Malaysian Society for Quality in Health (hereinafter called
MSQH).
The undersigned agrees to assists the surveyors appointed by the MSQH to survey the premises, facilities, organisation and
operations, including documentation.
The undersigned hereby acknowledge to have read the Accreditation Survey Application terms and conditions and agrees to all
of them.
The undersigned certifies that the contents of this application form are true and correct.
Click here to enter a date.
Date this
(Name of Facility)
(Corporate Ownership)
Main Phone
Fax
Facility/Organisation
Email
1.
2.
Mailing Address
Address Name
Street 1
Street 2
Street 3
City
State
Postcode
Country
MALAYSIA
Customer Information
My organization is listed as below:- (Please tick (X) in the table below):
Public
Private
☐ Non Specialist
☐ Specialist (with 1 – 6 specialties)
Specialist
(with
1
–
6
specialties)
☐
☐ Specialist (with 7 or more specialties)
☐ Specialist (with 7 or more specialties)
(For private hospital: Please attach a copy of
☐ Medical Institution
your current hospital license)
☐ Hospital Kuala Lumpur
Signed on behalf of the above facility
☐ I hereby accept the terms and conditions as stated
Name
Date
Signed on behalf of MSQH
PIC/MDAC
Chief Executive Officer/Director
(Please print name & Chop)
(Please print name & Chop)
Click here to enter a date.
Name
Date
(See terms and condition attached)
Click here to enter a date.
MSQH-Surv 05
Issue 6/2014
Page 2
Accreditation Survey Application
Terms and Conditions
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The MSQH shall give consideration to the report of the surveyors following such survey and shall
by such method as they shall determine, and in consideration of such knowledge concerning the
hospitality/facility, determine the Accreditation status of that hospital/facility;
The MSQH shall have power to issue Certificates of Accreditation setting out the Accreditation
status of the hospital/facility;
Certificates of Accreditation shall be valid for one or three years or for such other duration as the
MSQH shall determine;
Certificates of Accreditation issued by the MSQH shall be and remain the property of the MSQH
and shall be held by a hospital/ facility at the pleasure of the MSQH and shall be recallable by
the MSQH for non-compliance with standards for any cause as determined by the MSQH and
when the MSQH by the signature of its officers recalls a certificate, the hospital/facility shall be
bound to surrender it;
Any hospital/facility shall have the right to request a review of an Accreditation ruling made by
the MSQH with respect to that hospital/facility provided that appeal is based upon evidence of
incomplete or inaccurate information available to the MSQH at the time the Accreditation status
of the hospital/facility was decided;
An intention to seek a request for review made by hospital/facility shall be considered valid if it is
lodged in writing and addressed to the Secretary of the MSQH within thirty (30) days of
notification to the hospital/facility of the Accreditation status by the MSQH. Supporting
documentation must be lodged within a further thirty (30) days. If this does not occur the appeal
will lapse. An appeal fee is to be paid when lodging the appeal notification.
During the survey, MSQH surveyors shall be supplied with all information needed and assisted
with the necessary arrangement for the assessment, including provision for examining
documentation and access to all areas, records and personnel.
MSQH shall have sole discretion to determine the method of hearing any review;
Any costs of the review process shall be borne by the appellant hospital/facility;
Decision of the review committee shall be final;
Neither the MSQH nor any number, officer or employee of the MSQH nor any person acting on
behalf of the MSQH shall be liable in respect of any loss or damage suffered by the applicant
hospital/facility as a result of an act or thing done or said or reported pursuant to an application
of an Accreditation survey. The loss or damage or willful act or default of the MSQH whether or
not such loss or damage is foreseeable or contemplated by the MSQH;
Should the ownership of the facility/organization change during the period of accreditation, the
MSQH must be informed.
MSQH shall have the right to withdraw the Accreditation Certificate in the event of major noncompliance to the standards and evidence of compromised Patient Safety.
The MSQH does not accept token/gift for individual surveyors during the survey process.
MSQH-Surv 05
Issue 6/2014
Page 3
DETAIL OF FACILITY REQUESTING MSQH SURVEY
Please complete the following details so that the MSQH may better assess the composition of the
survey team and the length of survey required.
1.
The hospital/facility opened in the year
and currently has the following number of
beds (please specify number in each type). Please note all beds must be declared. Should there
be any changes prior to the survey, contact the MSQH as soon as possible.
Medical
Day Surgery
Obstetric
Geriatric
Paediatric
Psychiatry
Rehabilitation
Critical Care
Surgical
Others
Total
2.
The hospital/facility has been surveyed previously.
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MSQH-Surv 05
Issue 6/2014
Page 4
3.
Please tick (X) in the table below to indicate the department of functions available:
Department/Services
1. Governance, Leadership and Direction
2. Environmental and Safety Services
3. Facility and Biomedical Equipment
Management and Safety
4. Nursing Services
5. Prevention and Control of Infection
6. Patient and Family Rights
7. Health Information Management System
8. Emergency Services
9. Clinical Services – Generic
9. Clinical Services – Inpatients
9. Clinical Services – Maternity
9. Clinical Services – Medical
9. Clinical Services – Surgical
☐
☐
Department/Services
9B. Clinical Services – Oncology Services
9B. Clinical Services – Gynaecology Oncology
☐
☐
☐
9B. Clinical Services – Paediatric Oncology
☐
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9. Clinical Services – Obstetrics & Gynaecology
☐
10. Anaesthetic Services
11. Operating Suite Services
11. Operating Suite Services – Emergency OT
11. Operating Suite Services – Neurosurgery OT
11. Operating Suite Services – Maternity OT
11. Operating Suite Services – Paediatric OT
12. Ambulatory Care Services
12. Ambulatory Care Services – Day Care Surgery
12. Ambulatory Care Services – Endoscopy Services
12. Ambulatory Care Services – Day Care (Medical)
12. Ambulatory Care Services – Day Care
9. Clinical Services – Paediatrics
☐
12. Ambulatory Care Services
9. Clinical Services – Orthopaedics
☐
12. Ambulatory Care Services
9. Clinical Services – Otorhinolaryngology (ENT)
☐
12. Ambulatory Care Services
9. Clinical Services – Ophthalmology
9. Clinical Services – Dermatology
9. Clinical Services – Nephrology
9. Clinical Services – Neurology
9. Clinical Services – Psychiatry & Mental Health
9. Clinical Services – Forensic Psychiatry
9. Clinical Services – Respiratory Medicine
9. Clinical Services – Urology
9. Clinical Services – Cardiothoracic Surgery
9. Clinical Services – Hepatology
9. Clinical Services – Hepatobiliary
9. Clinical Services – Hand & Microsurgery
9. Clinical Services – Neurosurgery
9. Clinical Services – Oral Maxillofacial Surgery
9. Clinical Services – Paediatric Surgery
9. Clinical Services – Paediatric Dentistry
9. Clinical Services – Plastic & Reconstructive
☐
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13. Critical Care Services – Generic
13. Critical Care Services – ICU
13. Critical Care Services – Urology/Nephrology ICU
13. Critical Care Services – Neurosurgery ICU/HDU
13. Critical Care Services – CCU
13. Critical Care Services – CICU
13. Critical Care Services – Paediatric CICU
13. Critical Care Services – NICU
13. Critical Care Services – Paediatric NICU
13. Critical Care Services – Maternity NICU
13. Critical Care Services – PICU
13. Critical Care Services – SCN
13. Critical Care Services – CRW
13. Critical Care Services – HDU
13. Critical Care Services – HDU (Medical)
13. Critical Care Services – Maternity HDU
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13. Critical Care Services – Paediatric HDU
☐
9. Clinical Services – Palliative Care
9. Clinical Services – Sports Medicine
☐
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9. Clinical Services – TB Management
☐
13. Critical Care Services – Burns Care Unit
13. Critical Care Services – Paediatric Burns Care Unit
13A. Critical Care Services – Labour / Delivery
9. Clinical Services – Breast Care Centre
☐
9. Clinical Services – Nuclear Medicine
☐
14. Radiology / Diagnostic Imaging Services
14. Radiology / Diagnostic Imaging Services –
9. Clinical Services – Genetics
9A. Clinical Services – Cardiology Services
9A. Clinical Services – Paediatric Cardiology
☐
☐
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15. Pathology Services
15. Pathology Services – Microbiology Medicine
16. Blood Transfusion Services
Surgery
(Paediatrics)
– Day Care
(Urology/Lithotripsy)
– Special Diagnostic
Services
– Special Diagnostic &
Transplant
Services
Nuclear Medicine (Investigation only)
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MSQH-Surv 05
Issue 6/2014
Page 5
17. Rehabilitation Medicine Services
☐
23. Forensic Medicine Services
☐
17A. Allied Health Professional Services –
☐
23A. Mortuary Services
☐
☐
24. Standards for General Application
☐
☐
24. Standards for General Application – General
☐
☐
24. Standards for General Application – Executive
☐
24. Standards for General Application – Public
☐
24. Standards for General Application – TB Control
☐
24. Standards for General Application – Day Care
☐
24. Standards for General Application – Home Care
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24. Standards for General Application – Clinical
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24. Standards for General Application – Lactation
18. Pharmacy Services
☐
24. Standards for General Application – Horticulture
☐
19. Central Sterilising Supply Services
(CSSS)
☐
24. Standards for General Application – Child
☐
20. Housekeeping Services
☐
24. Standards for General Application – Community
21. Linen Services
☐
24. Standards for General Application – Traditional &
22. Food and Dietary Services
☐
24. Standards for General Application – Day Care
Physiotherapy Services
17B. Allied Health Professional Services –
Occupational Therapy Services
17C. Allied Health Professional Services –
Dietetic Services
17D. Allied Health Professional Services –
Speech-Language Pathology Services
17E. Allied Health Professional Services –
Audiology Services
17F. Allied Health Professional Services –
Optometry Services
17G. Allied Health Professional Services –
Health Education Services
17H. Allied Health Professional Services –
Medical Social Services
17I. Allied Health Professional Services –
Psychology Counselling Services
17J. Allied Health Professional Services –
Clinical Psychology Services
Outpatient Services/Primary Care Services
Health Screening/Wellness Centre
Health/Occupational Health
Training Unit
(Psychiatry)
Research Centre
Resource Centre
Intervention
Mental Health
Complementary Medicine
(Breast Cancer Resource Centre)
☐
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MSQH-Surv 05
Issue 6/2014
Page 6
4.
Please provide details of major changes in bed numbers, roles, extra services etc since the last
survey.
5.
Does the hospital/facility have any subsidiary units under its current management structure? If so,
please detail the name, bed numbers, type of each unit and distance from the main facility.
6.
Please provide the following details separately as applicable:
CLINICAL DEPARTMENTS
DIAGNOSTIC DEPARTMENTS
CRITICAL CARE UNITS
MSQH-Surv 05
Issue 6/2014
Page 7
ACADEMIC DEPARTMENTS
COMMUNITY/OUTREACH SERVICES: NUMBER OF UNITS, FULL DESCRIPTION AND DISTANCE FROM
MAIN FACILITY
7.
Other relevant information which may help in the allocation of numbers of survey days
and surveyors.
FOR OFFICE USE
Survey Date
Total no. of services
Total no. of surveyors required
Accreditation Fee