On a productive morning at Shah Alam Hospital, a significant briefing session took place at the Auditorium, gathering 53 liaison officers from all departments. The session, which ran from 9:30 AM to 1:00 PM, served as a crucial starting point in the hospital's preparations for MSQH (Malaysian Society for Quality in Health) accreditation.

Key Areas of Focus

At a briefing session on 8th January 2025, several key areas were highlighted as crucial milestones in our departmental roadmap. These initiatives align with our organizational goals and emphasize the importance of timely and accurate deliverables.

Creating the Departmental Profile Document

One of the primary documents discussed was the Departmental Profile, a comprehensive document that each department/unit must create to summarize its importance, tasks, and functions. A template for the departmental profile has been made available on both the intranet and the HSAS MSQH web app. The submission deadline for this document is set for 7th March 2025.

Performance Indicator Report

A significant portion of the briefing was dedicated to the Performance Indicator Report, which must be prepared by certain departments/units in accordance with MSQH requirements. The report will track and evaluate the performance indicators established by each department, and it should be completed up until 2025. The template for this report is also accessible via the intranet and the HSAS MSQH web app. The deadline for submission is 14th April 2025.

Uploading Evidence of Compliance

The process of Uploading Evidence of Compliance has been streamlined thanks to a user-friendly web app developed by the hospital's quality unit.

This app, accessible via the Web App www.hsas-msqh.site, allows departments to submit their documents efficiently while maintaining quality control and documentation standards. A demo is available on the web app to guide users through the upload process. Liaison officers have been advised to use consistent email addresses (preferably Gmail) when submitting documents to prevent confusion. The submission deadline for evidence upload is 14th April 2025.

Credential & Privileging Folder

Another key document emphasized during the session was the Credential & Privileging Folder (C&P), which plays a critical role in MSQH assessments. As highlighted by the secretariat, C&P documentation is frequently scrutinized by MSQH surveyors during audits. Each department/unit must prepare an up-to-date C&P folder based on a template provided by the quality unit. The submission deadline for the C&P folder is 31st January 2025.

Gap Analysis

Lastly, the session emphasize on Gap Analysis, a critical process that will be carried out in collaboration with MSQH surveyors. A Gap Analysis Presentation Template has been distributed to all departments/units to aid in the preparation. The gap analysis will take place on February 25, 2025, and all departments are required to submit their gap analysis documents by 14th February, 2025.

Looking Ahead

The first briefing session proved to be a great success, setting the tone for future preparation efforts leading up to the MSQH accreditation. Liaison officers left the session with a clear understanding of their roles and the next steps in the process. Several additional sessions are planned to provide further guidance on remaining tasks, ensuring that all departments meet the necessary requirements and deadlines.