RISK REDUCTION STRATEGIES OF SIQ’S KPI/ HPIA

KPI FOR 2017

DISCIPLINE INDICATOR STANDARD PERFORMANCE
Percentage of laboratory turnaround time ≥90% 86%
Pathology (LTAT) for urgent (STAT) Full Blood Count (FBC)
withnin (≤) 45 minutes
NO. MAIN SUB-FACTORS REMEDIAL ACTIONS PRIORITY STATUS
CONTRIBUTING
ACTIONS RESPONSIBLE
FACTORS
PERSON
1. High workload STAT requests To educate clinicians Dr Azura Ongoing
(Work and care as high as the impact of abusing Suliman
Environment routine requests STAT requests
Factors)
Only one To add another Cik Marina Waiting
dedicated results terminal for validation Shah for new
validation tender to
terminal for be
STAT requests awarded
as other 3
terminals are
used for
demography,
morphology
section and
information
counter
 RISK REDUCTION STRATEGIES OF SIQ’S KPI/ HPIA
KPI FOR 2017
DISCIPLINE INDICATOR STANDARD PERFORMANCE
Percentage of laboratory turnaround time ≥90% 86%
Pathology (LTAT) for urgent (STAT) Full Blood Count (FBC)
withnin (≤) 45 minutes
NO. MAIN SUB-FACTORS REMEDIAL ACTIONS PRIORI STATUS
CONTRIBUTING TY
ACTIONS RESPONSIBLE
FACTORS
PERSON

2. Frequent network Current LIS To upgrade LIS Head of Ongoing

problem due to system is DOS System to improve Unit/Head of
outdated and based which is results management Department/Pe
unstable outdated and ngarah HKL
Laboratory need
Information middleware to
System (LIS) connect to
(Task and analyzers
Technology
Factors) Intermittent Continous monitoring LIS vendor/Caw
interference in of the system by Teknologi
internet vendor(analyzer&LIS) Maklumat
connection going
 FBC WORKLOAD

MONTH ROUTINE STAT TOTAL

JULY 2017 14092 14344 28436

AUGUST 2017 14264 12269 26533
SEPTEMBER 2017 13301 11132 24433
OCTOBER 2017 14937 9062 23999
NOVEMBER 2017 14513 9075 23588
DECEMBER 2017 14053 8056 22109
 RISK REDUCTION STRATEGIES OF SIQ’S KPI/ HPIA
KPI FOR 2017
DISCIPLINE INDICATOR STANDARD PERFORMANCE
Percentage of laboratory turnaround time ≥90% 86%
Pathology (LTAT) for urgent (STAT) Full Blood Count (FBC)
within (≤) 45 minutes
NO. MAIN SUB-FACTORS R whicEMEDIAL ACTIONS PRIORITY STATUS
CONTRIBUTING
ACTIONS RESPONSIBLE
FACTORS
PERSON

3. Task and Analyzer Put up for Cik Marina Tender in

Technology frequently procurement of new Shah process
breakdown (in analyzer through new
use since 2010) tender

4. Staff factor  Lab frequently Cik Marina Ongoing

(Compliance) receives Shah
insufficient
sample which is Reminder letter sent to
analysed the requester to
manually (affects adhere to the
LTAT) minimum required
volume
 RISK REDUCTION STRATEGIES OF SIQ’S KPI/ HPIA
KPI FOR 2017
DISCIPLINE INDICATOR STANDARD PERFORMANCE
Pathology Percentage of correct detection of malaria 100% 98.15
parasites by microscopy examination
NO. MAIN SUB-FACTORS REMEDIAL ACTIONS PRIORI STATUS
CONTRIBUTING TY
FACTORS ACTIONS RESPONSIBLE
PERSON
1. Patient Factor Patient has
been treated,
count low and
morphology of
parasites may
be changed

2. Staff Factor  Staff unable To improve staff Training Ongoing

to detect low competency officer
parasitemia through more
count training