PRIVATE HEALTHCARE FACILlTIES AND SERVICES ACT 1998 [ACT 586]&

PRIVATE HEALTHCARE FACILlTIES AND SERVICES

(PRIVATE HOSPITALS AND OTHER PRIVATE HEALTHCARE FACILlTIES)

REGULATIONS 2006

MANUAL ON

ASSESSABLE DEATH REPORTING

Private Medical Practice Control Section (CKAPS)

Medical Practice Division

Ministry of Health Malaysia

DECEMBER 2010

# CONTENTS PAGE

1. Charter 3

2. Goals of Reporting of Assessable Death 3

3. Objectives of Reporting of Assessable Death 3

4. Guiding Principles 4

5. Methodology

5.1. Interpretation of "Assessable" Death 5

5.2. Notification and Data Collection of Assessable Death for Mortality 5Review

5.3. Retrieval of Patient Medical Record 5

5.4. Confidentiality 6

5.5. Fate of Notified Form AD-1 6

6. Mortality Assessment Committee at Facility Level 6

7. Access to the NMAC 6

Acknowledgement 7

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ASSESSABLE DEATH REPORTING

1. CharterA person in charge of a private healthcare facility ar service (PHFS) shall ensurethat every medical ar dentai practitioner who administers any anaesthesia aranaesthetic ar medical ar surgical procedure ar uses any medical technology onany patient whose death that occurs within the PHFS, is an assessable death shallnotify the Director General the particulars of the assessable death as requiredunder subsection 67(1), Act 586.

2. Goals of Reporting of Assessable Death

2.1. To provide information relating to the assessable deaths for NationalMortality Assessment Committee (NMAC) consideration.

2.2. To determine the extent (if any) to which anaesthesia ar any anaestheticprocedure, medical technology ar any medical procedure ar surgery ar anysurgical procedure contributed to the assessable death.

2.3. To determine whether the assessable death might have been averted hadthe effects ar consequences of anaesthesia ar anaesthetic procedure,medical technology ar any medical procedure ar surgery ar any surgicalprocedure, had been better ar more fully understood ar provided for.

2.4. To improve the quality and standards of PHFS by promoting the safe andefficient use of anaesthetic, medical ar surgical procedures, ar medicaltechnology based on NMAC's finding(s) and recommendation(s).

3. Objectives of Reporting of Assessable Death

3.1. To collate data on "assessable" mortality in PHFS.

3.2. To systematically assess the quality of anaesthetic, medical (includingmedical technology) and surgical (including dentai) services and the qualityof supporting services and logistics by systematically reviewing theinformation relating to assessable deaths which is aimed at identifyingshortfaIIs in such services hence taking remedial measures to prevent thefuture occurrence of similar deaths.

3.3. To look into relevant aspects of anaesthetic, medical and surgical care.

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3.4. To identify shortfaIIs in the delivery of the anaesthetic, medical and surgicalservices.

3.5. To recommend remedial measures in order to promote and attain the safeand efficient use of anaesthetic, medical or surgical (including dentai)procedures, or medical technology.

3.6. To provide feedback on the results of the investigations to the relevantprivate healthcare facility or service as well as the registered medicalpractitioner.

4. Guiding PrinciplesIn fulfilling its functions, the reporting of assessable death is bound by the folIowingstatutory guiding principles:

4.1. Secrecy and Confidentiality (section 70)

4.1.1. Confidentiality of all information is assured and strictly adhered to,except for the folIowing purposes:

(a) Purposes connected with the functions of NMAC;

(b) Purpose of an investigation of any alleged crime; or

(c) Purpose of any criminal proceeding,

where all identification data from the reports are expunged beforebeing coded and reviewed by the members or "assessors" of theNMAC who thus have no knowledge of the origin of the cases.

4.1.2. No person shall be compelled or permitted to divulge, in any civilproceeding, any information relating to assessable death and no suchinformation shall be admissible as evidence in any civil proceedings.

4.2. Non-punitive (subsection 66(3))

The inquiry looks at system problems and deficiencies and does notapportion blame to any individual.

4.3. Objectivity

Each case is independently assessed by members or "assessors" of theNMAC who are specially chosen and who are in no way connected with the

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institution or persons in question before making any conclusion and/arrecommendation.

5. MethodologyThis is a retrospective study of assessable death s in the PHFS.

5.1. Interpretation

"Assessable death", under section 64 of the Private Healthcare Facilities andServices Act 1998 refers to death that, in the opinion of any medicalpractitioner or dentai practitioner, may be related to anaesthesia or anyanaesthetic procedure, or medical technology or any medical procedure, orsurgery or any surgical procedure.

5.2. Notification and Data Collection of Assessable Death for Mortality Review

5.2.1. It is the duty of the person in charge of the private healthcare facilityor service to ensure that the relevant medical or dentai practitioner(s)notify the Director General of Health, Malaysia (Secretariat) in writingand preferably via electronic means of that death with in 72 hoursafter he learns the occurrence of the death (subsection 67(1)) usingForm AD-1.

5.2.2. All assessable death patients' medical records are retained in theprivate healthcare facility or service and marked "CONFIDENTIAL".Completed notification forms (AD-1) will be sent to the NMACSecretariat at the Ministry of Health.

5.2.3. In addition, the medical or dentai practitioner(s) or any other relevantpersons may be required to furnish all or any specified information intheir possession relating to the assessable death including c1inical ormedical records or any other material or documents that are withintheir control and may be required to assist the NMAC WorkingCommittee in any possible way as delineated under subsections 68(1)and (2), Act 586.

5.2.4. Form AD-1 can be accessed and downloadable athttp://medicalprac.moh .gov .my

5.3. Retrieval of Patient Medical Record

The patient medical record shall be kept in a safe place after any assessabledeath to enable medical or dentai practitioners to have access to them forreporting.

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http://medicalprac.moh

5.4. Confidentiality

Information in the Form AD-1 shall be expunged of all identification data(such as the name of the deceased person, the names of the relevantmedical or dentai practitioners involved and the name of the privatehealthcare facility or service or place where the death occurred pursuant tosubsection 68(3), Act 586.

5.5. Fate of Notified Form AD-1

All Form AD-1 which have been completed and notified shall be kept untilsuch a time as when analysis of data and the annual report have beencompleted, after which they may be destroyed.

6. Mortality Assessment Committee at Facility LevelA PHFS is encouraged to conduct its own investigation into any assessable deathby form ing an internal or in-house mortality assessment committee as providedunder subsections 72(1), (2) and (3), Act 586 and the findings of such investigationmay be used to improve services of the PHFS.

7. Access to the NMACThe Committee can be contacted through its Secretariat at the folIowing:

NMAC Secretariat.Private Medical Practice Control SectionMedical Practice DivisionMinistry of Health MalaysiaLevel 3, Block E1, Complex EFederal Government Administrative Centre62590 PUTRAJAYA

Tel. No.: 03 - 88831296/1270Fax No.: 03 - 8881 0901/0902Email: irad@moh.gov.myWebsite: http://medicalprac.moh.gov.my

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mailto:irad@moh.gov.myhttp://medicalprac.moh.gov.my

Acknowledgement

• Medical Practice Division, Ministry of HealthD Dr. Nooraini binti BabaD Dr. Ahmad Razid bin SallehD Dr. Mohd Anis bin Haron @ HarunD Dr. Afidah binti Ali

• Medical Development Division, Ministry of HealthD Dr. PAA Mohamed Nazir bin Abdul Rahman

• Association of Private Hospitais of MalaysiaD Dr. T. MahadevanD Puan Jasimah binti Hassan

• Pharmaceutical Services DivisionD Puan Wan Mohaina binti Wan MohammadD Puan Norleen binti Mohamed Ali

• KPJ Healthcare Berhad

• Pantai Holdings Berhad

• Sunway Medical Centre

• Gleneagles Medical Centre

• Penang Adventist Hospital

• National Heart Institute

• Columbia Asia Sdn. Bhd.

• Sime Darby Healthcare

• Assunta Hospital

• KPJ Selangor Specialist Hospital

• Alpha Specialist Centre

• Econ Medicare Centre

• Lions Nursing Homes

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