GUIDELINES. Electronic Assessment. HOspital Accreditation Program

Transcription

1 GUIDELIES Electronic Assessment HOspital Accreditation Program

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3 1 2 ITRODUCTIO The MSQH Electronic Hospital Accreditation Program (My e-hap) is a web based application for Hospital to submit self-assessment documents and for surveyors to conduct external self-assessment of hospitals and completes survey reports over the web. The application has been designed under the guidance of a steering committee comprising surveyors, quality managers and information technology personnel. These guidelines are provided as a useful and practical source of information for healthcare facilities and services undergoing MSQH Accreditation to complete the Questionnaires. The Self-Assessment Questionnaires should be completed using MSQH Electronic Healthcare Accreditation Program (My e-hap) and submit to the MSQH six weeks prior to the actual survey. HOW TO APPLY MY e-hap ACCESS Introduction My e-hap 2.1 The My e-hap access must be request by the Person in Charge of the facilities/organisation. 2.2 The Access Application form (Refer Appendix 2) can be download from MSQH website at The Person in Charge must assign the respondents for each of the services for enable MSQH process the request for My e-hap access to relevant personal. 2.4 Send the scanned copy of the completed form via fax at or to accreditation@msqh.com.my 2.5 The access request will be mailed to your Person in Charge of the facilities/organisation, within 4 working days. Access to MSQH Electronic Healthcare Accreditation Program (My e-hap) must be approved by the Person in Charge of each facilities/organisations. The Person in Charge is the person to whom all MSQH correspondence is sent. 3 HOW TO ACCESS MY e-hap 3.1 My e-hap users must have member access to the MSQH Electronic Healthcare Accreditation Program (My e-hap) website Access to My e-hap can only be provided by the MSQH if the Person in Charge for your organisation has provided approval. 3.3 The My e-hap is accessed via the homepage of the MSQH Website by clicking on the My e-hap login button. This will open the My e-hap login screen. Enter your user Id and Password and click on the login button. 3.4 The next screen displayed will depend on the user s level of access. For My e-hap there are two levels of access: Administrator Level This person/s have ultimate responsibility for My e-hap for the facility/ organisation Respondent Level This person/s has access to what has been assigned to them by an administrator in My e-hap. The Person in Charge and CEO of the facility/organisation is the Administrator and Head/Staff of Department or Head/Staff of Services is the Respondents for MSQH Electronic Healthcare Accreditation Program (My e-hap) Electronic Assessment Tool User ame Password Login Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/2015 3

4 4 MY e-hap ACCESS LEVEL 4.1 For My e-hap there are two levels of access: Administrator Level Respondent Level This person/s have ultimate responsibility for My e-hap for the facility This person/s has access to what has been assigned to them by an administrator in My e-hap. 4.2 The Person in Charge and CEO has an administrator level access. Administrator will all share one My e-hap data record and be able to edit, view and delete each other s work. 4.3 The Person in Charge/CEO can also nominate others to have access to My e-hap at Respondent level. It will then be the Administrator/s decision as to what My e-hap criteria and recommendations the Respondent/s are assigned to and what type of data record they have. 4.4 The Head of Department/ Head of Services have a respondent level access. This person/s has access to what has been assigned to them by an administrator in My e-hap. 4.5 The Person in Charge of the facility/organisation must be responsibility to submit the final completed My e-hap data to the MSQH. Once submitted, the data becomes Read Only and no new information can be added to the Self-Assessment. Introduction My e-hap 5 Malaysian Hospital Accreditation Standards and Questionnaires The Malaysian Hospital Accreditation Standards and Questionnaires are interrelated. You should read the Standards and refer to the Questionnaires accordingly to be able to understand and interpret the requirements of the Standards YEARS ACCREDITATIO 12 MOTH COMPLIACE REPORT FOCUS SURVEY 12 MOTH COMPLIACE 36 MOTH COMPLIACE REPORT MOTH / SURPRISED SURVEILLACE SURVEY MOTH COMPLIACE REPORT REPORT 1 YEAR ACCREDITATIO 24 MOTH COMPLIACE REPORT 03 6 Who Should Complete and submit the Questionnaires? 6.1. The Questionnaires shall be completed by relevant heads of departments or departmental coordinators and signed and endorsed by the Hospital Director or Chief Executive Officer. 6.2 The Person in Charge of the facility/organisation should be responsibility to submit the final completed My e-hap data to MSQH accompanying with Pre- Assessment Questionnaires Endorsement Form (Refer Appendix 3) Facility/ Profile Performance Indicator 6.3. The Pre- Assessment Questionnaires Endorsement Form can be downloading from MSQH website at and fax at or at msqh@msqh.com.my to MSQH. 6.4 The completed Questionnaires and accompanying documents establishes your first communication opportunity with the surveyors. You should therefore ensure the surveyors gain a favorable impression of your facility from the completed Questionnaires and understand the unique characteristics of your staff and the services you provide. 6.5 It is important that all staff in your facility be involved in completing sections of the Questionnaires and understands the intent of the Standards. Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/2015 4

5 7 8 9 Departments or Functions for The facility requesting for survey is required to complete the Facility Detail and Application for forms (Refer Appendix 1). This will assist the MSQH in determining the number of surveyors required and the duration of the survey. At the same time it will be important to establish with the MSQH what services are to be assessed under the Standards for General Applications Examples on further classifications of services: Governance Administration* Account* Public Relations* Library* Purchasing* Information System* - Communication Allied Health Professional Services - Physiotherapy - Occupational Therapy - Patients Education - Social Welfare Services Critical Care Services CICU ICU Intensive Care Unit HDW - Haemodialysis These activities need not be addressed separately. SELF ASSESSMET - GEERAL Clinical Services - Generic - Inpatients - Medical - ephrology - Dermatology - eurology - Psychiatry & Mental Health - uclear Medicine - General Surgery - Plastic & Reconstructive - Orthopaedics - Ophthalmology - Ortorhinolaryngology - Urology - eurosurgery - Oral Surgery - Obstetrics & Gynaecology - Paediatrics Medical, Surgical, Dentistry - Radiotheraphy & Oncology - Rehabilitation Medicine Standards for General Applications - Palliative Care 8.1 Self-assessment of your facility s compliance with the Malaysian Hospital Accreditation Standards is an important part of your preparation. The inclusion of the hospital rating and comment is to: Assist the facility s preparation; Recognise the facility s own evaluation and how it meets the standards; Assist the surveyors understanding of differences in the interpretation of the Standards by the facility and the need for discussion and clarification; and Highlight the areas for discussion, clarification, remedial measures and future plans. 8.2 The surveyors take note of the hospital ratings but the ratings do not replace the surveyors need to assess any of the standards. Hospital ratings are not submitted for voting by MSQH councilors, nor have they direct influence on the final Accreditation Status. SELF ASSESSMET - COMPLIACE RATIGS 9.1 In completing the questionnaires, facilities should insert the appropriate compliance code for the section, providing only one answer for each survey items. Always check the exact wording in the Standards to ensure you understand the intent of the Standards. 9.2 Consider the following when entering the compliance codes: Introduction My e-hap SUBSTATIALLY COMPLIES should be given when you believe sufficient key elements of the standards are achieved (80% and above, given the standards as set out in the Malaysian Hospitals Accreditation Standards and their supporting notes) O-COMPLIACE C C is used when the facility does not comply with the standard (below 49% compliance). PARTIALLY COMPLIACE PC PC means that there is a substantial part of the criterion that does not comply with the standard (50% to 79% compliance). OT APPLICABLE A A is used when the criterion/standard is not relevant to the facility Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/2015 5

6 Section a GUIDELIE HOSPITAL SURVEY USIG MY E-HAP

7 A1 Access or login into My e-hap website 1.1 Go to MSQH Website by clicking on the My e-hap login button. This will open the My e-hap login screen. 1.2 Enter your user name and Password and click on the login button. 1.3 There are two access level for organisation / facility member users: Administrator user level users with this access level will have full read/write access to the administrator s data set Respondent user level users with this level will only have access as determined by the administrator Electronic Assessment Tool Hospital - Administrator User ame Password Login A2 LOGGED in AS ADMIISTRATOR 2.1 Login details are indicated on top of the explorer screen. From this screen double-click on the organisation/facility to view and edit data. You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Find - Look for: Find Code Active Date Last Date test account 2 18-Mar-2015 D - i rg isa i /fa i t n e i dat. 1 items displayed Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/2015 7

8 A3 OPE SURVEY PHASE 3.1 To open a current survey phase, double-click on the phase that has In progress status. *If no phase is currently In progress please contacts MSQH to initiate the next survey phase. View s Initiate Manage Users Close You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Product Phase Phase Date PSA Due Date MSQH 4th Edition Hospital v4 18-Mar-2015 MSQH 4th Edition 12 C Report v4 18-Mar-2016 MSQH 4th Edition MSQH 4th Edition Surprised Surveillance 36 C Report v4 18-Mar Mar-2018 D - i I Pro es Sta u Status In Progress ot Started ot Started ot Started Report Hospital - Administrator 4 items displayed View s Manage Users Product Phase Phase Date PSA Due Date Status ot started In Progress Completed Closed Login Details Auto Save Change Password Log Out Used to display the survey data in the work area. Used to manage users Displays the product the member is using. Eg MSQH refer to the MSQH accreditation program. Displays the phases of the accreditation program Displays the date when the event will occur or has happened. Displays the submission date of the pre-survey documentation. Displays the status of the phase: a future phase. due for completion by the facility/organisation. submitted to MSQH and not yet finished. a finished phase. Displays the member organisation's name, user access level and user's name displays Auto-Save status (On/Off) to adjust status go to Housekeeping, Auto-Save Status. (When the Autosave status is on it will automatically save your most current EAT data at 30 minute intervals) * We recommend leaving the Autosave status on for the whole duration of the survey process. This function is used to change the user's password. This function is to logout of MSQH EAT. Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/2015 8

9 A4 Identify and select service standards 4.1 Administrator of the facility/organisation must identify and select service standards as listed. 4.2 Expand the Housekeeping section by clicking on the symbol. Click on Select Service Standards 4.3 Identify and [ ] Service Standards 4.4 After select all related service standards click Save 4.5 All selected service standards will display in Standards & Criteria section Hospital v4 4.2 Previous 4.3 Standards & Criteria Reports Housekeeping Auto Save Status Select Service Standard Assign Respondent Submit Exit You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Select Service Standards Save 4.4 Service Standard Cancel 2. Environmental and Safety Services 3. Facility and Biomedical Equipment and Safety 4. ursing 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 Hospital - Administrator 9. Clinical Services - Obstetrics & Gynaecology 9. Clinical Services - Paediatrics 9. Clinical Services - Othopaedics Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/2015 9

10 A5 ASSIG RESPODETS 5.1 Administrator assigns the respondents to related service standards. ** The Head of Department/ Head of Services have a respondent level access. This person/s has access to what has been assigned to them by an administrator in My e-hap 5.2 Expand the Housekeeping section by clicking on the symbol. Click on Assign Respondents 5.3 Click User and it display the respondent of the facility/organisation who has access to My e-hap. 5.4 User response displays the status of the user: Open : User can access and make a changes Closed : User can access but cannot make a changes 5.2 Hospital v4 Previous Standards & Criteria Reports Housekeeping Auto Save Status Select Service 5.6 Standard Assign Respondent Submit Exit You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Assign Service Standards User: 5.5 Save 5.7 Cancel Respondent 1 Respondent 2 Respondent 3 Service Standards 5.3 Recommendations 2. Environmental and Safety Services 3. Facility and Biomedical Equipment and Safety 4. ursing Services 5. Prevention and Control of Infection 6. Patient and Family Rights 7. Health Information Management System 8. Emergency Services 5.4 User Response: Open Closed Hospital - Administrator 9. Clinical Services - Generic 9. Clinical Services - Inpatients 9. Clinical Services - Maternity 5.5 Choose user to assign related service standard 5.6 Identify the respondent and [ ] to assign related service standard 5.7 Click Save ote User Response: Open Closed Respondent can access, edit, view and delete the work to what has been assigned to them by an administrator in My e-hap User Response: Open Closed Respondent can access but cannot edit, view and delete the work and no new information can be added to what has been assigned to them by an administrator in My e-hap To open please contact Hospital Administrator Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

11 A6 STADARDS & CRITERIA RATIG 6.1 All the standards and criteria can be viewed on the navigation bar located on the left hand side of the screen. Expand the Standards and Criteria section by clicking on the symbol. 6.2 Current Criterion is displayed at the top of the screen Expand the service standards you want to rate and then the standards. Click on the criterion to begin rating that criterion 6.3 The Ratings radio buttons are displayed on the right hand side of screen. Record your facility s ranking in the rating column for each question. You should rank each survey item for all service areas applicable to your facility. 6.4 Click Save 6.5 Click ext to go to the next criterion or click at any criterion (at the left side) to proceed with other criterion Hospital v4 Previous 6.1 Standards & Criteria Governance, Leadership and Direction Hospital Comments You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Criterion Save 6.2 Cancel Previous ext ORGAISATIO AD MAAGEMET 1.1.1: The Governing Body adopts a governing framework that constituted the internal legislation that will fit the particular needs and circumstances of the Facility. These may be called Hospital By-Laws and Medical Staff By-Laws, which include Rules and Regulations, Terms of Reference, Policies, Resolutions or other similar terms and they govern the actions of the Board and management of the Facility. The governing framework is essential for the governance of the Facility. 6.5 Hospital - Administrator 6.2 Standard Criterion Criterion Criterion Criterion Criterion a Criterion b Criterion c Criterion d Criterion e Criterion f Criterion g Criterion h Criterion i Criterion Standard Standard Item Elements (a) The documented statements of Vision and Mission,goals, objectives and values are what the services want to achieve (b) Statements reflect the Facility s roles and aspirations in the community that it serves (c) The goals of the service are achieved by the objectives as stated. (d) The goals and objectives are consistent with professional standards, guidelines and relevant legislation (e) Statements are monitored, reviewed and revised as required accordingly. 6.3 PC C A PC C A Clear ote Administrator can view, modify and delete respondent s rating and comments Facilities are encouraged to provide an honest assessment of their performance against the Standards. This will assist the surveyors in their role of helping organizations to achieve solutions to service delivery issues and attainment of Accreditation Status Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

12 7 HOSPITAL COMMETS 7.1 The facility s ratings and comments provide explanations of how the facility sees it meets the standards and what actions a facility has in place to address the specific standards. If there is anything you feel the surveyors should be particularly aware of, you should write clearly in the Hospital Comment section and convey this to the surveyors when they are on survey 7.2 Expand the Standards and Criteria section by clicking on the symbol. Expand the service standards you want to rate and then the standards 7.3 Click Hospital Comment under each service standards Where a PC/C/A rating has been applied, you should make a comment in the Hospital Comment section Equally, where you believe greater explanation would assist the survey team (e.g. highlighting particular efforts), you may also choose to comment 7.4 Enter your response/comments 7.5 Click Save Hospital v4 Previous You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Hospital 7.5 Comments: Governance, Leadership and Direction Save Cancel Hospital - Administrator 7.1 Standards & Criteria Governance, Leadership and Direction Hospital Comments 7.4 Enter your response / comments 7.3 Standard Criterion Criterion Criterion Criterion Criterion a Criterion b Criterion c Criterion d Criterion e Criterion f Criterion g Criterion h Criterion i Criterion Standard Standard Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

13 8 RATIG SUMMARY 8.1 The function allows users to view ratings by a selection based on the rating status of criteria 8.2 Select in the navigation menu on the left hand side of the screen. The screen will be displayed 8.3 By default the criteria all rated will be displayed. Users can select all those that not been rated or by a rating category, by changing the selection category at the top of the screen (e.g. ot rated, All rated,, PC, C, A). 8.4 By double-clicking on a selected standard/criterion, the system will display the selected criterion screen that allows users to make changes to responses. Hospital v4 Previous Standards & Criteria Reports Housekeeping Auto Save Status Select Service Standard 8.2 Assign Respondent Submit You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out ot Rated All Rated Function Standard Criterion Rating PC C A a b c d PC PC A Hospital - Administrator 2. Environmental and Safety Services Exit 2. Environmental and Safety Services Environmental and Safety Services Environmental and Safety Services a 2. Environmental and Safety Services b 2. Environmental and Safety Services c 2. Environmental and Safety Services Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

14 RESPODET LEVEL HOSPITAL SURVEY

15 1 Access or login into My e-hap website 1.1 Go to MSQH Website by clicking on the My e-hap login button. This will open the My e-hap login screen. 1.2 Enter your user name and Password and click on the login button. 1.3 There are two access level for organisation / facility member users: Administrator user level users with this access level will have full read/write access to the administrator s data set Respondent user level users with this level will only have access as determined by the administrator Electronic Assessment Tool Hospital - Respondent User ame Password Login 2 LOGGED in AS RESPODET 2.1 Login details are indicated on top of the explorer screen. From this screen double-click on the organisation/facility to view and edit data. 2.2 Users with this level will only have access as determined by the administrator You are logged in as: \ Admin \ Respondent Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Find - Look for: Find Code Active Date Last Date test account 2 18-Mar-2015 D - i rg isa i /fa i t n e i dat. 1 items displayed Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program 15

16 3 OPE SURVEY PHASE 3.1 To open a current survey phase, double-click on the phase that has In progress status. *If no phase is currently In progress please contacts MSQH to initiate the next survey phase. View s Initiate Close You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Product Phase Phase Date PSA Due Date MSQH 4th Edition Hospital v4 18-Mar-2015 D - i I Pro es Sta u Status In Progress Report Hospital - Respondent 1 items displayed View s Manage Users Product Phase Phase Date PSA Due Date Status ot started In Progress Completed Closed Login Details Auto Save Change Password Log Out Used to display the survey data in the work area. Used to manage users Displays the product the member is using. Eg MSQH refer to the MSQH accreditation program. Displays the phases of the accreditation program Displays the date when the event will occur or has happened. Displays the submission date of the pre-survey documentation. Displays the status of the phase: a future phase. due for completion by the facility/organisation. submitted to MSQH and not yet finished. a finished phase. Displays the member organisation's name, user access level and user's name displays Auto-Save status (On/Off) to adjust status go to Housekeeping, Auto-Save Status. (When the Autosave status is on it will automatically save your most current EAT data at 30 minute intervals) * We recommend leaving the Autosave status on for the whole duration of the survey process. This function is used to change the user's password. This function is to logout of MSQH EAT. Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

17 4 STADARDS & CRITERIA RATIG 4.1 All the standards and criteria can be viewed as determined by administrator on the navigation bar located on the left hand side of the screen. Expand the Standards and Criteria section by clicking on the symbol. 4.2 Current Criterion is displayed at the top of the screen Expand the service standards you want to rate and then the standards. Click on the criterion to begin rating that criterion 4.3 The Ratings radio buttons are displayed on the right hand side of screen. Record your facility s ranking in the rating column for each question. You should rank each survey item for all service areas applicable to your facility. 4.4 Click Save 4.5 Click ext to go to the next criterion or click at any criterion (at the left side) to proceed with other criterion Hospital v4 Previous 4.1 Standards & Criteria Governance, Leadership and Direction Hospital Comments You are logged in as: \ Admin \ Respondent Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Criterion Save 4.2 Cancel Previous ext ORGAISATIO AD MAAGEMET 1.1.1: The Governing Body adopts a governing framework that constituted the internal legislation that will fit the particular needs and circumstances of the Facility. These may be called Hospital By-Laws and Medical Staff By-Laws, which include Rules and Regulations, Terms of Reference, Policies, Resolutions or other similar terms and they govern the actions of the Board and management of the Facility. The governing framework is essential for the governance of the Facility. 4.5 Hospital - Respondent 4.2 Standard Criterion Criterion Criterion Criterion Criterion a Criterion b Criterion c Criterion d Criterion e Criterion f Criterion g Criterion h Criterion i Criterion Standard Standard Item Elements (a) The documented statements of Vision and Mission,goals, objectives and values are what the services want to achieve (b) Statements reflect the Facility s roles and aspirations in the community that it serves (c) The goals of the service are achieved by the objectives as stated. (d) The goals and objectives are consistent with professional standards, guidelines and relevant legislation (e) Statements are monitored, reviewed and revised as required accordingly. 4.3 PC C A PC C A Clear ote Administrator can view, modify and delete respondent s rating and comments Facilities are encouraged to provide an honest assessment of their performance against the Standards. This will assist the surveyors in their role of helping organizations to achieve solutions to service delivery issues and attainment of Accreditation Status Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

18 5 HOSPITAL COMMETS 5.1 The facility s ratings and comments provide explanations of how the facility sees it meets the standards and what actions a facility has in place to address the specific standards. If there is anything you feel the surveyors should be particularly aware of, you should write clearly in the Hospital Comment section and convey this to the surveyors when they are on survey 5.2 Expand the Standards and Criteria section by clicking on the symbol. Expand the service standards you want to rate and then the standards 5.3 Click Hospital Comment under each service standards Where a PC/C/A rating has been applied, you should make a comment in the Hospital Comment section Equally, where you believe greater explanation would assist the survey team (e.g. highlighting particular efforts), you may also choose to comment 5.4 Enter your response/comments 5.5 Click Save Hospital v4 Previous You are logged in as: \ Respondent \ Respondent Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Hospital 5.5 Comments: Governance, Leadership and Direction Save Cancel Hospital - Respondent 5.1 Standards & Criteria Governance, Leadership and Direction Hospital Comments 5.4 Enter your response / comments 5.3 Standard Criterion Criterion Criterion Criterion Criterion a Criterion b Criterion c Criterion d Criterion e Criterion f Criterion g Criterion h Criterion i Criterion Standard Standard Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

19 6 RATIG SUMMARY 6.1 The function allows users to view ratings by a selection based on the rating status of criteria 6.2 Select in the navigation menu on the left hand side of the screen. The screen will be displayed 6.3 By default the criteria all rated will be displayed. Users can select all those that not been rated or by a rating category, by changing the selection category at the top of the screen (e.g. ot rated, All rated,, PC, C, A). 6.4 By double-clicking on a selected standard/criterion, the system will display the selected criterion screen that allows users to make changes to responses. Hospital v4 Previous Standards & Criteria Reports Housekeeping Auto Save Status Submit Response You are logged in as: \ Respondent \ Respondent Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out ot Rated All Rated PC C A Function Standard Criterion Rating a b PC Hospital - Respondent c PC Exit d A 2. Environmental and Safety Services Environmental and Safety Services Environmental and Safety Services Environmental and Safety Services a 2. Environmental and Safety Services b 2. Environmental and Safety Services c 2. Environmental and Safety Services Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

20 SUBMIT SURVEY HOSPITAL SURVEY

21 1 SUBMISSIO OF COMPLETED SURVEY QUESTIOAIRES BY ADMIISTRATOR 1.1 The completed Questionnaires should be sent to the MSQH six weeks prior to the survey. 1.2 The Person in Charge of the facility/organisation that has administrator level access has the responsibility to submit the final completed survey to the MSQH. 1.3 Expand the housekeeping section by clicking on the symbol. 1.4 Click on Submit 1.5 Click on Submit button to submit the survey 1.6 Pop up Message will appear. Click OK 1.7 Once submitted, the data becomes Read Only and no new information can be added to the Self-Assessment. To re-open/edit your responses please contact MSQH Hospital v4 Previous You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Submit Submit 1.5 Hospital - Submit Standards & Criteria Click on Submit button to submit the survey Reports Housekeeping Auto Save Status 1.3 Select Service Standard Message from My e-hap Assign Respondent Submit Exit 1.4 submitted successfully. After submission, if you need to change your submitted data or if your next phase is not activated, please contact MSQH OK 1.6 Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

22 2 SUBMISSIO OF COMPLETED SURVEY QUESTIOAIRES BY Respondent 2.1 Click on Submit Response 2.2 If you are ready to submit the survey click on completed under the your response status 2.3 Click Save 2.4 Once submitted, the data becomes Read Only and no new information can be added to the Self-Assessment. 2.5 To re-open/edit your responses please contact your administrator or MSQH Hospital v4 Previous Standards & Criteria You are logged in as: \ Respondent \ RespondentAcc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Submit Save 2.3 Cancel Your response status Hospital - Submit Reports Housekeeping Auto Save Status Submit Response 2.1 Exit Open Completed 2.2 ote User Response: Open Closed Once respondent completed the survey, the respondent status in user response automatically change to closed Respondent can access but cannot edit, view and delete the work and no new information can be added to what has been assigned to them by an administrator in My e-hap Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

23 3 Document to Accompany the Completed Questionnaires 3.1 The following documents should accompany the completed Questionnaires: The Pre- Assessment Questionnaires Endorsement Form. (Please refer Appendix 1 or can be downloading from MSQH website at ) Facility/ Profile with organisation Chart Hospital License for Private Hospital Performance Indicators (Continuous from previous submission) 3.2 Please to accreditation@msqh.com.my or fax to Hospital - Submit Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

24 SURVEY REPORT HOSPITAL SURVEY

25 1 GEERATE PRE-SURVEY REPORT 1.1 The report function allows users to export My e-hap data into Microsoft Word Document. My e-hap is compatible with MS Word 2003 and later versions 1.2 Expand the Reports section by clicking on the symbol. 1.3 There are 4 reports available for organisation: Member details Report Respondent Assignment (Administrator Only) 1.4 Click on the report you wish to export to Microsoft Word Hospital v4 Previous Standards & Criteria You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Hospital - Report Reports 1.4 Member Details 1.2 Report Respondent Assignment 1.3 Housekeeping Exit LOGGED in AS RESPODET Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

26 2 GEERATE PRE-REPORT USIG ITERET EPLORER 2.1 A file download box will appear 2.2 Click Open to open your report When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document 2.2 Hospital - Report Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

27 3 GEERATE PRE-REPORT USIG GOOGLE CHROME 3.1 A download file will appear at the bottom of the page 3.2 Click the arrow 3.3 Select Open. It will automatically open the report in Microsoft Word 3.4 When saving your reports, choose Save and make sure that file type is a Word Document Hospital v4 Previous Standards & Criteria Reports You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Hospital - Report Member Details Report Respondent Assignment Exit 3.3 Open Always open files of this type Show in folder Cancel Report.doc Show all downloads GEERATE PRE-REPORT USIG MOZILA FIREFO A file download will appear 4.2 Select Open with micrososft Word 4.3 It will automatically open the report in Microsoft Word. 4.4 When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

28 5 GEERATE FIAL SURVEY REPORT You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out View s Initiate Manage Users Product Phase Phase Date PSA Due Date Status MSQH 4th Edition Hospital v4 18-Mar-2015 Closed Close MSQH 4th Edition 12 C Report v4 18-Mar-2016 MSQH 4th Edition Surprised Surveillance 18-Mar-2017 MSQH 4th Edition 36 C Report v4 18-Mar-2018 ot Started Report 5.2 ot i Started t d loa ot Started n p Hospital - Final Report 4 items displayed 5.1 Login into My e-hap Website 5.2 Click on icon to download the final report 6 GEERATE FIAL REPORT USIG ITERET EPLORER 6.1 A file download box will appear 6.2 Click Open to open your report 6.3 When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

29 7 GEERATE FIAL REPORT USIG GOOGLE CHROME 7.1 A download file will appear at the bottom of the page 7.2 Click the arrow 7.3 Select Open. It will automatically open the report in Microsoft Word 7.4 When saving your reports, choose Save and make sure that file type is a Word Document Hospital v4 Previous Standards & Criteria Reports Member Details Report Respondent Assignment You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Hospital - Final Report Exit 7.3 Open Always open files of this type Show in folder Cancel Report.doc Show all downloads GEERATE FIAL REPORT USIG MOZILA FIREFO A file download will appear 8.2 Select Open with micrososft Word 8.3 Click OK 8.4 It will automatically open the report in Microsoft Word. 8.5 When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

30 Section B GUIDELIE 12 th Month Compliance Report USIG MY E-HAP

31 B1 Access or login into My e-hap website 1.1 Go to MSQH Website by clicking on the My e-hap login button. This will open the My e-hap login screen. 1.2 Enter your user name and Password and click on the login button. 1.3 There are two access level for organisation / facility member users: Administrator user level users with this access level will have full read/write access to the administrator s data set Respondent user level users with this level will only have access as determined by the administrator Electronic Assessment Tool 12th Month Complaince Report User ame Password Login B2 LOGGED in AS ADMIISTRATOR 2.1 Login details are indicated on top of the explorer screen. From this screen double-click on the organisation/facility to view and edit data. You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Find - Look for: Find Code Active Date Last Date test account 2 18-Mar-2015 D - i rg isa i /fa i t n e i dat. 1 items displayed Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

32 B3 OPE SURVEY PHASE 3.1 Double click on 12 C Report v4 phase, the status must In Progress *If no phase is currently In progress please contacts MSQH to initiate the next survey phase. View s Initiate Manage Users Close You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Product Phase Phase Date PSA Due Date MSQH 4th Edition Hospital v4 18-Mar-2015 MSQH 4th Edition 12 C Report v4 18-Mar-2016 MSQH 4th Edition Surprised Surveillance D - i MSQH 4th Edition 36 C Report v4 12 C R p 4 Pha 18-Mar Mar-2018 Status Closed In Progress ot Started ot Started Report 12th Month Complaince Report 4 items displayed 3.2 After double clicking a In Progress survey phase, Administrator will see a list of all criteria and recommendations from previous survey (12th Month Compliance Report) Respondent will see a list of all criteria and recommendations from previous surveys (12th Month Compliance Report) that have been assigned to them by the Administrator 12 C Report v You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Previous Previous Standards & Criteria Reports Housekeeping Auto Save Status Select Service Standard Assign Respondent Submit Exit Save Cancel Recom o Criterion Date HPR Rating Completed Closed Hospital v Mar-2015 PC Hospital v a a 18-Mar-2015 PC Hospital v Mar-2015 PC Hospital v Mar-2015 PC Hospital v Mar-2015 PC Hospital v Mar-2015 PC Hospital v Mar-2015 PC Hospital v Mar-2015 PC Hospital v Mar-2015 PC Hospital v a a 18-Mar-2015 PC Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

33 B4 ASSIG RESPODETS TO RECOMMEDATIOS 4.1 Administrator assigns the respondents to related recommendations ** The Head of Department/ Head of Services have a respondent level access. This person/s has access to what has been assigned to them by an administrator in My e-hap 4.2 Expand the Housekeeping section by clicking on the symbol. Click on Assign Respondents 4.3 Click User and it display the respondent of the facility/organisation who has access to My e-hap. 4.4 Click Recommendations Tab 4.5 User response displays the status of the user: Open : User can access and make a changes Closed : User can access but cannot make a changes 12 C Report v Previous Standards & Criteria Reports Housekeeping Auto Save Status Select Service 4.7 Standard Assign Respondent Submit Exit You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Assign Respondent User: 4.6 Save 4.8 Cancel Respondent 1 Respondent 2 Respondent 3 Service Standards Recommendation # Hospital v Hospital v a Hospital v Hospital v Hospital v User Response: Open Closed Recommendations Criterion a th Month Complaince Report Hospital v Hospital v Hospital v Hospital v Hospital v a a 4.6 Choose user to assign related recommendations 4.7 Identify the respondent and [ ] to assign related recommendations 4.8 Click Save ote User Response: Open Closed Respondent can access, edit, view and delete the work to what has been assigned to them by an administrator in My e-hap User Response: Open Closed Respondent can access but cannot edit, view and delete the work and no new information can be added to what has been assigned to them by an administrator in My e-hap To open please contact Hospital Administrator Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

34 B5 12 th Month compliance report 5.1 Click on Recommendation from previous survey Administrator will see a list of all recommendations from previous survey (12th Month Compliance Report) Respondent will see a list of all recommendations from previous surveys (12th Month Compliance Report) that have been assigned to them by the MSQH 5.2 This screen displays all of the open Recommendations for the organisation. Other information displayed includes the recommendation number, the criterion to which it relates, the date of the survey at which it was made, if it is an High Priority (HPR) and whether facility have ticked that it is completed. 5.3 Double click on the recommendation line to edit or select/highlight the line of relevant recommendation and click the Edit button on the top tool bar. 12 C Report v Previous Standards & Criteria5.1 Reports Housekeeping Auto Save Status Select Service Standard Assign Respondent Submit Exit You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Previous Edit 5.3 Recom o Criterion Date HPR Rating Completed Closed Hospital v Mar-2015 PC Hospital v a Hospital v Hospital v Hospital v Hospital v Hospital v Hospital v Hospital v Hospital v a a a 18-Mar Mar Mar Mar Mar Mar Mar Mar Mar-2015 PC PC PC PC PC PC PC PC PC Month Compliance Report Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

35 5.4 or s previous survey 5.5 or s Comments from previous survey 5.6 Action Taken tab 5.7 Facility/ should fill in the action taken to address the recommendation 5.8 Completion Due By: Time frame for complete the action taken 5.9 Responsibility of: Responsible of which department / person 5.10 Complete Radio Button: The status of the action taken 5.11 Click Save 5.12 Click ext to go to the next recommendation to proceed with other recommendations 12 C Report v Previous Standards & Criteria You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Previous : #Hospital v a Save Cancel Standard > Criterion a Previous ext 12 Month Compliance Report Reports Housekeeping Auto Save Status Select Service Standard Assign Respondent Recommendation: HPR: Risk Rating: /A The Hospital Management to review the organisation charts to meet the requirement of the Private Healthcare Facilities and Services Act 1998, Regulations 2006 to reflect clinical governance. Comment: The organization charts are not standardized in some departments.the organization charts are not standardized in some departments. Submit Action Taken 5.6 Exit 5.7 En f ac i t t ad es ec nda i ormal HTML Words: 0 Character: 0 Completion Due By: Complete: Yes o 5.10 Responsibility of: Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

36 SUBMIT COMPLAICE REPORT 12th Month Complaince Report

37 1 SUBMISSIO OF COMPLETED 12th Month Complaince report BY ADMIISTRATOR 1.1 The completed Questionnaires should be sent to the MSQH at 12th Month of the accreditation status 1.2 The Person in Charge of the facility/organisation that has administrator level access has the responsibility to submit the final completed 12th Month Complaince Report to the MSQH. 1.3 Expand the housekeeping section by clicking on the symbol. 1.4 Click on Submit 1.5 Click on Submit button to submit the survey 1.6 Pop up Message will appear. Click OK 1.7 Once submitted, the data becomes Read Only and no new information can be added to the Complaince Report To re-open/edit your responses please contact MSQH 12 C Report v Previous You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Submit Submit Month Compliance Report Standards & Criteria Click on Submit button to submit the survey Reports Housekeeping Auto Save Status 1.3 Select Service Standard Message from My e-hap Assign Respondent Submit Exit 1.4 submitted successfully. After submission, if you need to change your submitted data or if your next phase is not activated, please contact MSQH OK 1.6 Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

38 2 SUBMISSIO OF COMPLETED 12th Month Complaince Report BY Respondent 2.1 Click on Submit Response 2.2 If you are ready to submit the complaince report click on completed under the your response status 2.3 Click Save 2.4 Once submitted, the data becomes Read Only and no new information can be added to the complaince report. 2.5 To re-open/edit your responses please contact your administrator or MSQH Hospital v4 Previous You are logged in as: \ Respondent \ RespondentAcc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Submit Save 2.3 Cancel 12 Month Compliance Report Standards & Criteria Your response status Reports Housekeeping Auto Save Status Submit Response 2.1 Exit Open Completed 2.2 ote User Response: Open Closed Once respondent completed the survey, the respondent status in user response automatically change to closed Respondent can access but cannot edit, view and delete the work and no new information can be added to what has been assigned to them by an administrator in My e-hap Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

39 3 Document to Accompany the Completed Questionnaires 3.1 The following documents should accompany the completed Questionnaires: Support Document on your action taken Performance Indicators (Continuous from previous submission) 3.2 Please to or fax to Month Compliance Report Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

40 Report 12th Month Complaince Report

41 1 GEERATE 12 th month compliance REPORT Hospital v4 1.2 Previous Standards & Criteria Reports Respondent Housekeeping Assignment Housekeeping Member Details Recommendations from previous 1.4 Report 1.3 You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out 1.1 The report function allows users to export My e-hap data into Microsoft Word Document. My e-hap is compatible with MS Word 2003 and later versions 1.2 Expand the Reports section by clicking on the symbol. 1.3 There are 4 reports available for organisation: Member details previous survey Report Respondent Assignment (Administrator Only) 1.4 Click on the previous survey report to export to Microsoft Word 12 Month Compliance Report Exit 2 GEERATE FIAL 12 th Month Compliance REPORT You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out View s Initiate Manage Users Product Phase Phase Date PSA Due Date Status Report MSQH 4th Edition Hospital v4 18-Mar-2015 Closed Close MSQH 4th Edition MSQH 4th Edition MSQH 4th Edition 12 C Report v4 Surprised Surveillance 36 C Report v4 18-Mar Mar Mar-2018 Closed ot Started ot i Started t d loa n p 4 items displayed 2.1 The final report can be download after MSQH Technical Officer review and upload the report into the My e-hap. 2.2 Click on the symbol to download the report Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

42 2 GEERATE 12 th month compliance REPORT USIG IE 2.1 A file download box will appear 2.2 Click Open to open your report When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document Month Compliance Report Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

43 3 GEERATE 12 th month compliance REPORT USIG GOOGLE CHROME 3.1 A download file will appear at the bottom of the page 3.2 Click the arrow 3.3 Select Open. It will automatically open the report in Microsoft Word 3.4 When saving your reports, choose Save and make sure that file type is a Word Document Hospital v4 Previous Standards & Criteria Reports Member Details Report Respondent Assignment You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out 12 Month Compliance Report Exit 3.3 Open Always open files of this type Show in folder Cancel Report.doc Show all downloads GEERATE 12 th month compliance REPORT USIG MOZILA FIREFO 4.1 A file download will appear 4.2 Select Open with micrososft Word 4.3 It will automatically open the report in Microsoft Word. 4.4 When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

44 SECTIO C GUIDELIE Surprise Surveillance USIG MY E-HAP

45 Surprise Surveillance SURVEY 1.1 The Surprise Surveillance is conducted to all accredited hospitals awarded a Four-Year Accreditation Status at the 24th month of accreditation period. 1.2 The facility is required, in the same way as for a full survey, to conduct a self-assessment of all departments/units. 1.3 MSQH will open the Surveillance in My e-hap 16 weeks prior to the 24th month of the accreditation period 1.4 This self-assessment document must reach MSQH through MSQH Electronic Hospital Accreditation Program (My e-hap) six (6) weeks before the 24th month of the accreditation period together with Standards and Assessment Tool for Chronic Dialysis Treatment (if applicable), two copies of the latest service profile of the facility, statistics on performance indicators and Endorsement Form (MSQH-Surv 25) * Kindly download the Standards and Assessment Tool for Chronic Dialysis Treatment from the MSQH website. Objective / rationale 1.1 To ensure continuous compliance to Malaysian Society for Quality in Health (MSQH) Standards and foster CQI by MSQH Accredited Facilities and Services. ors for the surprise surveillance survey 3.1 MSQH CEO will select the team for the surprise surveillance survey. Each team constitute a minimum of two (2) surveyors who were not involved as surveyors for the facility in the current cycle. SElection of services 4.1 Services selected for surprise surveillance survey to be related to Patient Safety and to include services rated overall as Partial Compliance/on Compliance (PC/C) in the previous survey. umber of survey day 5.1 One (1) day from 8:00am to 5:00pm Surprise Surveillance 6 otifications of Surprise Surveillance 6.1 Facility: CEO shall inform the Person In Charge of the Facility two (2) weeks prior to the visit. 6.2 ors: One week before the date, the survey team shall be noted of their availability. 7 8 Methods & assessment 7.1 Surprise surveillance survey emphasis on general compliance to MSQH Standards for Healthcare Facilities Services (HCFS) especially for compliance to regulatory/statutory requirements and evidence of continuous quality improvement. 7.2 The Chief or will inform the facility on the selected services to be surveyed at the introduction briefing. 7.3 ors will conduct the survey for services selected and validate the remedial actions taken on the recommendations from the previous survey. 7.4 A summation conference will be held at the end of the surprise surveillance survey. This summation conference shall be attended by the Person In Charge of the hospital and the Heads of Department. REPORTIG 8.1 On completion of the surprise surveillance survey, the survey team shall submit the report of its findings and recommendations to MSQH Secretariat. Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

46 9 Accreditation Status Decision 9.1 Decision on the continuation of the accreditation status will depend on the performance and impact on Patient Safety matters. The survey team will recommend one of the followings: Maintain the current accreditation status Recommendations with Action Plans for Implementation in six (6) months period subject to verification. The accreditation status for the Facility remains status quo Withdrawal of certification ote Accreditation Status shall be withdrawn if the surprise surveillance survey reveals that safety and quality of care have been compromised by the facility. The MSQH shall submit the report to two (2) councillors for voting. In the event, no decision is reached; a third councillor will be requested to vote. Thereafter, the decision will be final. Surprise Surveillance Decision on Surprise Surveillance Recommendation by or Maintain Current Accreditation Status Recommendations with Action Plans for implementation in six (6) months Withdrawal of Accreditation Status MSQH Secretariat review MSQH Councillor (2) Satisfactory actions taken Unsatisfactory actions (subject to verification) Status Quo Withdrawal of Certification CEO endorses the result and informs the hospital in writing CEO endorses the result President informs the hospital in writing Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

47 1 Access or login into My e-hap website 1.1 Go to MSQH Website by clicking on the My e-hap login button. This will open the My e-hap login screen. 1.2 Enter your user name and Password and click on the login button. 1.3 There are two access level for organisation / facility member users: Administrator user level users with this access level will have full read/write access to the administrator s data set Respondent user level users with this level will only have access as determined by the administrator Electronic Assessment Tool User ame Password Login Surprise Surveillance - Administrator 2 LOGGED in AS ADMIISTRATOR 2.1 Login details are indicated on top of the explorer screen. From this screen double-click on the organisation/facility to view and edit data. You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Find - Look for: Find Code Active Date Last Date test account 2 18-Mar-2015 D - i rg isa i /fa i t n e i dat. 1 items displayed Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

48 3 OPE SURVEY PHASE 3.1 To open a current survey phase, double-click on the phase that has In progress status. *If no phase is currently In progress please contacts MSQH to initiate the next survey phase. View s Initiate Manage Users Close You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Product Phase Phase Date PSA Due Date MSQH 4th Edition Hospital v4 18-Mar-2015 MSQH 4th Edition 12 C Report v4 18-Mar-2016 MSQH 4th Edition MSQH 4th Edition 4 items displayed Surprised Surveillance 36 C Report v4 18-Mar Mar-2018 D - i I Pro es Sta u Status Closed Closed In Progress ot Started Report Surprise Surveillance - Administrator View s Manage Users Product Phase Phase Date PSA Due Date Status ot started In Progress Completed Closed Login Details Auto Save Change Password Log Out Used to display the survey data in the work area. Used to manage users Displays the product the member is using. Eg MSQH refer to the MSQH accreditation program. Displays the phases of the accreditation program Displays the date when the event will occur or has happened. Displays the submission date of the pre-survey documentation. Displays the status of the phase: a future phase. due for completion by the facility/organisation. submitted to MSQH and not yet finished. a finished phase. Displays the member organisation's name, user access level and user's name displays Auto-Save status (On/Off) to adjust status go to Housekeeping, Auto-Save Status. (When the Autosave status is on it will automatically save your most current EAT data at 30 minute intervals) * We recommend leaving the Autosave status on for the whole duration of the survey process. This function is used to change the user's password. This function is to logout of MSQH EAT. Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

49 4 Identify and select service standards 4.1 Administrator of the facility/organisation must identify and select service standards as listed. 4.2 Expand the Housekeeping section by clicking on the symbol. Click on Select Service Standards 4.3 Identify and [ ] Service Standards 4.4 After select all related service standards click Save 4.5 All selected service standards will display in Standards & Criteria section 24 / Surprise Surveillance 4.2 Previous 4.3 Standards & Criteria Reports Housekeeping Auto Save Status Select Service Standard Assign Respondent Submit Exit You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Select Service Standards Save 4.4 Service Standard Cancel 2. Environmental and Safety Services 3. Facility and Biomedical Equipment and Safety 4. ursing 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 Hospital Surprise Surveillance - Administrator - Administrator 9. Clinical Services - Obstetrics & Gynaecology 9. Clinical Services - Paediatrics 9. Clinical Services - Othopaedics Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

50 5 ASSIG RESPODETS 5.1 Administrator assigns the respondents to related service standards. ** The Head of Department/ Head of Services have a respondent level access. This person/s has access to what has been assigned to them by an administrator in My e-hap 5.2 Expand the Housekeeping section by clicking on the symbol. Click on Assign Respondents 5.3 Click User and it display the respondent of the facility/organisation who has access to My e-hap. 5.4 User response displays the status of the user: Open : User can access and make a changes Closed : User can access but cannot make a changes You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out 24 / Surprise Surveillance Assign Service Standards 5.7 Previous Save Cancel Standards & Criteria Reports Housekeeping Auto Save Status Select Service 5.6 Standard Assign Respondent Submit Exit User: 5.5 Respondent 1 Respondent 2 Respondent 3 Service Standards 5.3 Recommendations 2. Environmental and Safety Services 3. Facility and Biomedical Equipment and Safety 4. ursing Services 5. Prevention and Control of Infection 6. Patient and Family Rights 7. Health Information Management System 8. Emergency Services User Response: Open Closed Surprise Surveillance - Administrator 9. Clinical Services - Generic 9. Clinical Services - Inpatients 9. Clinical Services - Maternity 5.5 Choose user to assign related service standard 5.6 Identify the respondent and [ ] to assign related service standard 5.7 Click Save ote User Response: Open Closed Respondent can access, edit, view and delete the work to what has been assigned to them by an administrator in My e-hap User Response: Open Closed Respondent can access but cannot edit, view and delete the work and no new information can be added to what has been assigned to them by an administrator in My e-hap To open please contact Hospital Administrator Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

51 6 STADARDS & CRITERIA RATIG 6.1 All the standards and criteria can be viewed on the navigation bar located on the left hand side of the screen. Expand the Standards and Criteria section by clicking on the symbol. 6.2 Current Criterion is displayed at the top of the screen Expand the service standards you want to rate and then the standards. Click on the criterion to begin rating that criterion 6.3 The Ratings radio buttons are displayed on the right hand side of screen. Record your facility s ranking in the rating column for each question. You should rank each survey item for all service areas applicable to your facility. 6.4 Click Save 6.5 Click ext to go to the next criterion or click at any criterion (at the left side) to proceed with other criterion 24 / Surprise Surveillance Previous Standards & Criteria Governance, Leadership and Direction Hospital Comments Standard Criterion Criterion Criterion Criterion Criterion a Criterion b Criterion c Criterion d Criterion e Criterion f Criterion g Criterion h Criterion i Criterion Standard Standard You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Criterion Save Item Elements 6.2 Cancel Previous ext ORGAISATIO AD MAAGEMET 1.1.1: The Governing Body adopts a governing framework that constituted the internal legislation that will fit the particular needs and circumstances of the Facility. These may be called Hospital By-Laws and Medical Staff By-Laws, which include Rules and Regulations, Terms of Reference, Policies, Resolutions or other similar terms and they govern the actions of the Board and management of the Facility. The governing framework is essential for the governance of the Facility. (a) The documented statements of Vision and Mission,goals, objectives and values are what the services want to achieve (b) Statements reflect the Facility s roles and aspirations in the community that it serves (c) The goals of the service are achieved by the objectives as stated. (d) The goals and objectives are consistent with professional standards, guidelines and relevant legislation 6.5 (e) Statements are monitored, reviewed and revised as required accordingly. 6.3 PC C A PC C A Clear Surprise Surveillance - Administrator ote Administrator can view, modify and delete respondent s rating and comments Facilities are encouraged to provide an honest assessment of their performance against the Standards. This will assist the surveyors in their role of helping organizations to achieve solutions to service delivery issues and attainment of Accreditation Status Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

52 7 HOSPITAL COMMETS 7.1 The facility s ratings and comments provide explanations of how the facility sees it meets the standards and what actions a facility has in place to address the specific standards. If there is anything you feel the surveyors should be particularly aware of, you should write clearly in the Hospital Comment section and convey this to the surveyors when they are on survey 7.2 Expand the Standards and Criteria section by clicking on the symbol. Expand the service standards you want to rate and then the standards 7.3 Click Hospital Comment under each service standards Where a PC/C/A rating has been applied, you should make a comment in the Hospital Comment section Equally, where you believe greater explanation would assist the survey team (e.g. highlighting particular efforts), you may also choose to comment 7.4 Enter your response/comments 7.5 Click Save 24 / Surprise Surveillance Previous 7.1 Standards & Criteria Governance, Leadership and Direction Hospital Comments You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Hospital 7.5 Comments: Governance, Leadership and Direction 7.4 Save Cancel Enter your response / comments Surprise Surveillance - Administrator 7.3 Standard Criterion Criterion Criterion Criterion Criterion a Criterion b Criterion c Criterion d Criterion e Criterion f Criterion g Criterion h Criterion i Criterion Standard Standard Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

53 8 RATIG SUMMARY 8.1 The function allows users to view ratings by a selection based on the rating status of criteria 8.2 Select in the navigation menu on the left hand side of the screen. The screen will be displayed 8.3 By default the criteria all rated will be displayed. Users can select all those that not been rated or by a rating category, by changing the selection category at the top of the screen (e.g. ot rated, All rated,, PC, C, A). 8.4 By double-clicking on a selected standard/criterion, the system will display the selected criterion screen that allows users to make changes to responses. 24 / Surprise Surveillance Previous Standards & Criteria Reports Housekeeping Auto Save Status Select Service Standard 8.2 Assign Respondent Submit You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out ot Rated All Rated Function Standard Criterion Rating PC C A a b c d PC PC A Surprise Surveillance - Administrator 2. Environmental and Safety Services Exit 2. Environmental and Safety Services Environmental and Safety Services Environmental and Safety Services a 2. Environmental and Safety Services b 2. Environmental and Safety Services c 2. Environmental and Safety Services Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

54 RESPODET LEVEL Surprise Surveillance

55 1 Access or login into My e-hap website 1.1 Go to MSQH Website by clicking on the My e-hap login button. This will open the My e-hap login screen. 1.2 Enter your user name and Password and click on the login button. 1.3 There are two access level for organisation / facility member users: Administrator user level users with this access level will have full read/write access to the administrator s data set Respondent user level users with this level will only have access as determined by the administrator Electronic Assessment Tool User ame Password Login Surprise Surveillance - Respondent 2 LOGGED in AS RESPODET 2.1 Login details are indicated on top of the explorer screen. From this screen double-click on the organisation/facility to view and edit data. 2.2 Users with this level will only have access as determined by the administrator You are logged in as: \ Admin \ Respondent Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Find - Look for: Find Code Active Date Last Date test account 2 18-Mar-2015 D - i rg isa i /fa i t n e i dat. 1 items displayed Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program 55

56 3 OPE SURVEY PHASE 3.1 To open a current survey phase, double-click on the phase that has In progress status. *If no phase is currently In progress please contacts MSQH to initiate the next survey phase. View s Initiate Close You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Product Phase Phase Date PSA Due Date MSQH 4th Edition 24/Surprise Surveillance 18-Mar items displayed D - i I Pro es Sta u Status In Progress Report Surprise Surveillance - Respondent View s Manage Users Product Phase Phase Date PSA Due Date Status ot started In Progress Completed Closed Login Details Auto Save Change Password Log Out Used to display the survey data in the work area. Used to manage users Displays the product the member is using. Eg MSQH refer to the MSQH accreditation program. Displays the phases of the accreditation program Displays the date when the event will occur or has happened. Displays the submission date of the pre-survey documentation. Displays the status of the phase: a future phase. due for completion by the facility/organisation. submitted to MSQH and not yet finished. a finished phase. Displays the member organisation's name, user access level and user's name displays Auto-Save status (On/Off) to adjust status go to Housekeeping, Auto-Save Status. (When the Autosave status is on it will automatically save your most current EAT data at 30 minute intervals) * We recommend leaving the Autosave status on for the whole duration of the survey process. This function is used to change the user's password. This function is to logout of MSQH EAT. Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

57 4 STADARDS & CRITERIA RATIG 4.1 All the standards and criteria can be viewed as determined by administrator on the navigation bar located on the left hand side of the screen. Expand the Standards and Criteria section by clicking on the symbol. 4.2 Current Criterion is displayed at the top of the screen Expand the service standards you want to rate and then the standards. Click on the criterion to begin rating that criterion 4.3 The Ratings radio buttons are displayed on the right hand side of screen. Record your facility s ranking in the rating column for each question. You should rank each survey item for all service areas applicable to your facility. 4.4 Click Save 4.5 Click ext to go to the next criterion or click at any criterion (at the left side) to proceed with other criterion 24 / Surprise Surveillance Previous 4.1 Standards & Criteria Governance, Leadership and Direction Hospital Comments You are logged in as: \ Admin \ Respondent Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Criterion Save 4.2 Cancel Previous ext ORGAISATIO AD MAAGEMET 1.1.1: The Governing Body adopts a governing framework that constituted the internal legislation that will fit the particular needs and circumstances of the Facility. These may be called Hospital By-Laws and Medical Staff By-Laws, which include Rules and Regulations, Terms of Reference, Policies, Resolutions or other similar terms and they govern the actions of the Board and management of the Facility. The governing framework is essential for the governance of the Facility. 4.5 Surprise Surveillance - Respondent 4.2 Standard Criterion Criterion Criterion Criterion Criterion a Criterion b Criterion c Criterion d Criterion e Criterion f Criterion g Criterion h Criterion i Criterion Standard Standard Item Elements (a) The documented statements of Vision and Mission,goals, objectives and values are what the services want to achieve (b) Statements reflect the Facility s roles and aspirations in the community that it serves (c) The goals of the service are achieved by the objectives as stated. (d) The goals and objectives are consistent with professional standards, guidelines and relevant legislation (e) Statements are monitored, reviewed and revised as required accordingly. 4.3 PC C A PC C A Clear ote Administrator can view, modify and delete respondent s rating and comments Facilities are encouraged to provide an honest assessment of their performance against the Standards. This will assist the surveyors in their role of helping organizations to achieve solutions to service delivery issues and attainment of Accreditation Status Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

58 5 HOSPITAL COMMETS 5.1 The facility s ratings and comments provide explanations of how the facility sees it meets the standards and what actions a facility has in place to address the specific standards. If there is anything you feel the surveyors should be particularly aware of, you should write clearly in the Hospital Comment section and convey this to the surveyors when they are on survey 5.2 Expand the Standards and Criteria section by clicking on the symbol. Expand the service standards you want to rate and then the standards 5.3 Click Hospital Comment under each service standards Where a PC/C/A rating has been applied, you should make a comment in the Hospital Comment section Equally, where you believe greater explanation would assist the survey team (e.g. highlighting particular efforts), you may also choose to comment 5.4 Enter your response/comments 5.5 Click Save 24 / Surprise Surveillance Previous Standards & Criteria Governance, Leadership and Direction Standard You are logged in as: \ Respondent \ Respondent Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Hospital Comments Criterion Criterion Criterion Criterion Criterion a Criterion b Criterion c Criterion d Criterion e Criterion f Criterion g Criterion h Criterion i Criterion Standard Standard Hospital 5.5 Comments: Governance, Leadership and Direction 5.4 Save Cancel Enter your response / comments Surprise Surveillance - Respondent Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

59 6 RATIG SUMMARY 6.1 The function allows users to view ratings by a selection based on the rating status of criteria 6.2 Select in the navigation menu on the left hand side of the screen. The screen will be displayed 6.3 By default the criteria all rated will be displayed. Users can select all those that not been rated or by a rating category, by changing the selection category at the top of the screen (e.g. ot rated, All rated,, PC, C, A). 6.4 By double-clicking on a selected standard/criterion, the system will display the selected criterion screen that allows users to make changes to responses. 24 / Surprise Surveillance Previous Standards & Criteria Reports Housekeeping Auto Save Status Submit Response You are logged in as: \ Respondent \ Respondent Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out ot Rated All Rated PC C A Function Standard Criterion Rating a b PC Surprise Surveillance - Respondent c PC Exit d A 2. Environmental and Safety Services Environmental and Safety Services Environmental and Safety Services Environmental and Safety Services a 2. Environmental and Safety Services b 2. Environmental and Safety Services c 2. Environmental and Safety Services Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

60 SUBMIT SURVEY Surprise Surveillance

61 1 SUBMISSIO OF COMPLETED SURVEY QUESTIOAIRES BY ADMIISTRATOR 1.1 The completed Questionnaires should be sent to the MSQH six weeks prior to the survey. 1.2 The Person in Charge of the facility/organisation that has administrator level access has the responsibility to submit the final completed survey to the MSQH. 1.3 Expand the housekeeping section by clicking on the symbol. 1.4 Click on Submit 1.5 Click on Submit button to submit the survey 1.6 Pop up Message will appear. Click OK 1.7 Once submitted, the data becomes Read Only and no new information can be added to the Self-Assessment. To re-open/edit your responses please contact MSQH You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out 24 / Surprise Surveillance Submit Previous 1.5 Submit Surprise Surveillance Standards & Criteria Click on Submit button to submit the survey Reports Housekeeping Auto Save Status 1.3 Select Service Standard Message from My e-hap Assign Respondent Submit Exit 1.4 submitted successfully. After submission, if you need to change your submitted data or if your next phase is not activated, please contact MSQH OK 1.6 Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

62 2 SUBMISSIO OF COMPLETED SURVEY QUESTIOAIRES BY Respondent 2.1 Click on Submit Response 2.2 If you are ready to submit the survey click on completed under the your response status 2.3 Click Save 2.4 Once submitted, the data becomes Read Only and no new information can be added to the Self-Assessment. 2.5 To re-open/edit your responses please contact your administrator or MSQH You are logged in as: \ Respondent \ RespondentAcc 2, Friday, January 23, 2015 Autosave: O Change Password Log out 24 / Surprise Surveillance Submit 2.3 Previous Save Cancel Surprise Surveillance Standards & Criteria Your response status Reports Housekeeping Auto Save Status Submit Response 2.1 Exit Open Completed 2.2 ote User Response: Open Closed Once respondent completed the survey, the respondent status in user response automatically change to closed Respondent can access but cannot edit, view and delete the work and no new information can be added to what has been assigned to them by an administrator in My e-hap Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

63 3 Document to Accompany the Completed Questionnaires 3.1 The following documents should accompany the completed Questionnaires: The Pre- Assessment Questionnaires Endorsement Form. (Please refer Appendix 1 or can be downloading from MSQH website at ) Facility/ Profile with organisation Chart Hospital License for Private Hospital Performance Indicators (Continuous from previous submission) 3.2 Please to accreditation@msqh.com.my or fax to Surprise Surveillance Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

64 SURVEY REPORT Surprise Surveillance

65 1 GEERATE PRE-SURVEY REPORT 1.1 The report function allows users to export My e-hap data into Microsoft Word Document. My e-hap is compatible with MS Word 2003 and later versions 1.2 Expand the Reports section by clicking on the symbol. 1.3 There are 4 reports available for organisation: Member details Report Respondent Assignment (Administrator Only) 1.4 Click on the report you wish to export to Microsoft Word You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out 24 / Surprise Surveillance Previous Standards & Criteria Surprise Surveillance Reports 1.4 Member Details 1.2 Report Respondent Assignment 1.3 Housekeeping Exit LOGGED in AS RESPODET Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

66 2 GEERATE PRE-REPORT USIG ITERET EPLORER 2.1 A file download box will appear 2.2 Click Open to open your report When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document 2.2 Surprise Surveillance Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

67 3 GEERATE PRE-REPORT USIG GOOGLE CHROME 3.1 A download file will appear at the bottom of the page 3.2 Click the arrow 3.3 Select Open. It will automatically open the report in Microsoft Word 3.4 When saving your reports, choose Save and make sure that file type is a Word Document You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out 24 / Surprise Surveillance Previous Standards & Criteria Reports Member Details Report Respondent Assignment Surprise Surveillance Exit 3.3 Open Always open files of this type Show in folder Cancel Report.doc Show all downloads GEERATE PRE-REPORT USIG MOZILA FIREFO A file download will appear 4.2 Select Open with micrososft Word 4.3 It will automatically open the report in Microsoft Word. 4.4 When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

68 5 GEERATE FIAL SURVEY REPORT View s Initiate Manage Users Close You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Product Phase Phase Date PSA Due Date MSQH 4th Edition Hospital v4 18-Mar-2015 MSQH 4th Edition 12 C Report v4 18-Mar-2016 MSQH 4th Edition MSQH 4th Edition Surprised Surveillance 36 C Report v4 18-Mar Mar-2018 Status Closed Closed Closed 5.2 ot Started i t d loa n p Report Surprise Surveillance 4 items displayed 5.1 Login into My e-hap Website 5.2 Click on icon to download the final report 6 GEERATE FIAL REPORT USIG ITERET EPLORER 6.1 A file download box will appear 6.2 Click Open to open your report 6.3 When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

69 7 GEERATE FIAL REPORT USIG GOOGLE CHROME 7.1 A download file will appear at the bottom of the page 7.2 Click the arrow 7.3 Select Open. It will automatically open the report in Microsoft Word 7.4 When saving your reports, choose Save and make sure that file type is a Word Document You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out 24 / Surprise Surveillance Previous Standards & Criteria Reports Surprise Surveillance Member Details Report Respondent Assignment Exit 7.3 Open Always open files of this type Show in folder Cancel Report.doc Show all downloads GEERATE FIAL REPORT USIG MOZILA FIREFO A file download will appear 8.2 Select Open with micrososft Word 8.3 Click OK 8.4 It will automatically open the report in Microsoft Word. 8.5 When saving your reports, Select the folder you want to save the report Give your file name Save as type: choose Microsoft Word Document Document Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/

70 SECTIO D GUIDELIE 36 th Month Compliance Report USIG MY E-HAP

71 B1 Access or login into My e-hap website 36th Month Complaince Report 1.1 Go to MSQH Website by clicking on the My e-hap login button. This will open the My e-hap login screen. 1.2 Enter your user name and Password and click on the login button. 1.3 There are two access level for organisation / facility member users: Administrator user level users with this access level will have full read/write access to the administrator s data set Respondent user level users with this level will only have access as determined by the administrator Electronic Assessment Tool User ame Password Login 2 LOGGED in AS ADMIISTRATOR 2.1 Login details are indicated on top of the explorer screen. From this screen double-click on the organisation/facility to view and edit data. You are logged in as: \ Admin \ Admin Acc 2, Friday, January 23, 2015 Autosave: O Change Password Log out Find - Look for: Find Code Active Date Last Date test account 2 18-Mar-2015 D - i rg isa i /fa i t n e i dat. 1 items displayed Malaysian Society for Quality in Health Manual & Guidelines for Electronic Hospital Accreditation Program Version 2/