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Accreditation By MSQH: Hospital Sipitang Experience.

Towards my end period working in Hospital Sipitang, I had a chance to experience the accreditation survey by MSQH (Malaysian Society for Quality in Health). Accreditation in general from my understanding is a process to ensure that an institution  comply to the latest standards which determined whether the institution is safe. This means that we do not just simply run a hospital, we are running it by high standards set by MSQH. It was a brainchild of Ministry of Health, Malaysian Medical Association, and Association of Private Hospital Malaysia.

Thus, we do not just simply do our job based on what we want to do, but we do it because someone ask us and monitor whatever we were doing. If you happen to visit a hospital, you can check whether that hospital is accredited or not. If it is, then you can rest assure that the hospital has been following the standard given by MSQH.

I was appointed to become a vice chairperson in my hospital accreditation committee and was given the honour to be the head of Standard 9. There a lot of standard set by MSQH and standard 9 is regarding clinical services in patient. It was a 'small' standard consisting of 5-6 pages list of standard that we need to follow. For me, sisters in charge in ward is the back bone of this standard because they are the one who are collecting most of the data for this standard.

By the way, those standards set by MSQH, does not mean you just follow it, but you need to prove it, you need to create a file for it. For example, if the standard told you to give correct treatment to every patient, then you have to make a file of patient record to prove it to MSQH. All standard for me are like open ended question. It is up to us to create a mechanism to record the data. There is no such form or example of record given by MSQH.

More or less, it was fun. For me at least, because I am a first timer on this. So i enjoyed it much. The final survey, though, very hard.

I wrote this post because of one thing...when we do a visit to a hospital which is already accredited to learn from them, I found that it is hard for me to get other people experience on this. Most of the time people would always told me regarding the standard provided by MSQH but that is not what I want. I want the real story of experience going through the survery/audit by MSQH.


Thus, after experiencing it first hand, perhaps I would like to share to other Medical officer out there on what does it feels like to be surveyed.

First of all, don't get too panic. But don't be like no panic at all. You need a bit of adrenaline to face this kind of survey.

Second of all, please have a mind set to document everything you do. Your meeting, your idea, your schedule, everything that you do in hospital. Then analyse it. I do not do this earlier before accreditation survey thus I find it very difficult to cope by the final few days towards the audit.

Third, be truth to yourself. Don't make up something you do not do or you will find it very hard to prove to the surveyor about the thing you did not do but you say you do. They always ask for evidence.

Fourth, Team work. This is important. Usually, in your hospital, you will divide on who will keep track on a certain standard, but in the end, during the survey they do not care, they will ask around and everyone need to answer.

Fifth, know you hospital well, then it should be fine.


During the survey, everyone will have a chance to be interviewed. All medical officer will have their opportunity to be interviewed thus is you are not in the committee, don't think you can just go through the survey without being involved in it.

The question they ask.....is very though. I am being honest here. All these nonsense people who told me, its nothing, its okay, they will not ask that deep, don't worry...are rubbish. They do ask everything and you need to be worry about it. So please be prepared. If you are prepared then you can answer them correctly.

You can't correct whatever you have answer. What you answer the first time, they will take it as it is. You can't change it after that unless you have evidence to prove it.

You can't lie to this surveyor, it's obvious. When a person is a director of a hospital for so many years, you being a medical officer, they won't be cheated by your lie on policy. They know it better.

To be honest, again, the survey is pretty damn scary. I feel suffocated for 3 days period of the survey ( they do survey for 3 days straight and include night survey). They test every policy that you have made. If you say you have red alert policy for maternity, they simple just initiate it to see whether people would run to labour room if the alert has been initiated.

For someone who cannot handle this kind of stress...maybe you should not work in a hospital in the first place. Even for someone who work in hospital and I myself encounter with stress situation everyday, I have to admit, the survey by MSQH is more stressful than that. (haha).


In the end, I have this thought. Why does this survey very hard to go through? Why can't it be like SPM or STPM or exam in University where you can feel that the exam was pretty easy in the end after you passed. You will have this kind of feeling - that was not hard after all-. But accreditation will always be hard for me. Why?

Because MSQH want us to be safe in our work. We are dealing with human lives everyday. Not just lives but also their quality of life. People expect the best treatment when they step in to hospital. Thus we were actually not doing this accreditation for ourselves but for patients. What is the different stepping into a killer house and into a hospital? This is the different. We were keeping up with the standards to ensure everyone stepping out from our hospital alive and to maintain the best of their quality of life.



These are the people who work hard for accreditation in my Hospital. All the Head of Unit, sisters, and medical officers enjoying their end of final survey celebration in Weston Wetland Park. 

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