National Blue Ocean Strategy(NBOS)
Cataract Surgery Centre Islamic Affair C

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The State of Selangor is the most populous state in Malaysia with a total population of 5.4 millions (2010 National census). It has 5 major Ministry of Health’s hospitals providing cataract surgery services but these hospitals also cater for subspeciality services in Ophthalmology as well as large spectrum of other general medical diseases. This has resulted in a severe backlog of cases needing cataract surgery ranging from 4 months to as long as 8 months. It was also noted that the waiting period was exponentially increasing over a 5 year period. With an aging population it was abvious that this was a problem which would get worse over time as the capacity of the present hospitals reached their limits. Government hospitals in Malaysia generally provide essential services to the lower as well as middle income groups in the country and thus cater for a large segment of the population in contrast to cataract services in the private sector. It was noted that a significant limitation to provide speedy cataract surgery to patients who needed treatment was the limited number of operating theatres available as there was a need to share operating theatres with other surgical disciplines. Increasing theatre time just for cataract surgery was not an option as this would cause a disruption in other services. It was as a result of this that the concept of satellite cataract surgery centre outside of the existing hospital premises was conceptualized.

B. Strategic Approach

 2. What was the solution?
YBhg Datuk Dr Noor Hisham Abdullah who is currently the Director General of Health, Malaysia proposed the solution.The solution consisted of a satellite cataract surgery centre which would have the advantages of not interfering with the pre-existing services in the hospitals as well as aid in decongesting patients away from the main hospitals. As the cataract surgery can be carried out under local anesthesia, a full complement of operating threatre and anesthetic equipment would not be needed thus saving cost significantly. It would cater for cases who do not have associated high risk factors for surgery. The core issue then was financing the setting up of this center. Numerous sources were explored and the Islamic Affair Council of the Federal Territory (Majlis Agama Islam Wilayah Persekutuan) also known as MAIWP showed their interest and enthusiasm. It was decided that this project should be carried out as part of the National Blue Ocean Strategy (NBOS) whereby multiple agencies both public and corporate would work together on projects which would be of benefit to the public. MAIWP is a corporate body which, as part of its core function, collects and distributes religious tithes paid by Muslims. Part of this collection is allocated for the benefit of the community at large. As the project was primarily for the benefit of the community and the need for cataract services was very much in high demand, it was deemed that this would be suitable project for the body to fund. It was agreed that MAIWP would fund the procurement of a suitable shophouse, renovate it and fully equip it for cataract surgery. The Ministry of Health, Malaysia would be responsible for all operational aspects including staffing, medications, consumables, ration for patients, maintenance of the center and utilities. By having two dedicated operating suites for cataract surgery in this center, it would have potential of carrying out as many as 30 cataract surgeries a day (approximately 218 working days a year) and up to 6500 surgery a year. This would be doubled the potential output of cataract surgery in the whole State of Selangor. By concentrating on pre and post operative care, as well as carrying out the cataract surgery in single center with two operating suites, efficiency could be maximized and all five major hospitals and two specialist Hospitals in Selangor could use this facility to maximise their cataract output in the state. It would result in a drastically shorter waiting time for patients to have their cataract surgery.

 3. How did the initiative solve the problem and improve people’s lives?
This project is part of wider initiative and part of the National Blue Ocean Strategy (NBOS). It is unique for the following reasons: a. It is the first time that cataract surgery is being carried out in the ultra clean operating threatre by the government sector outside of hospital premises. b. It is the first time that the goverment has built a dedicated daycare surgical center for high volume cataract surgery. c. It is the first time that cataract surgeons from multiple hospitals in the Minitry of Health, Malaysia come and operate at single center. d. It is the first time that an ‘outside’ agency (MAIWP) has built and equipped a dedicated surgical faciity for the Ministry of Health, Malaysia. e. It is the first time a solution of this nature has been implemented to drastically shorten waiting time for cataract surgery.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
In order to make this project a reality, the necessary measures had been taken to ensure the projects will get adequate funding from the sponsor i.e MAIWP. The Department of Ophthalmology, Hospital Selayang has been given the responsibility to find the suitable place and to write the proposal for the project which will include the area for the proposed location, the floor plan for the building or infrastructure and the instruments required for the center to function smoothly and of similar standard as other major hospital in Ministry of Health, Malaysia and the gold standard is Hospital Selayang which is one of the main teaching hospital for Selangor Sate and Ministry of Health, Malaysia. Earlier discussion between the sponsor MAIWP with Datuk Dr Noor Hisham (Deputy Director of Health at that time) and Chief Secretary to the Government of Malaysia were held to come to an agreement on the amount that was requested by the Department of Ophthalmology, Hospital Selayang. MAIWP has agreed to the amount of one-off payment which will include the procurement and the renovation of the builling to fulfil the requirement as the daycare with operation threatre and to include all necessary instruments for the safe surgery and convenient enviroment for the cataract patients. The total cost of RM 9.876 million was agreed. (RM 2.3 million for the purchased of shophouse, RM 2.4 million for the renovations of the building as per Minisry of Health requirement for Private Healthcare Facilities and Services Act - Daycare and Clinic Requirements and RM 5.176 million for the equipments). The Ophthalmology team had managed to locate the suitable area and building for the project. As the management and maintenance team are from Hospital Selayang, the ideal location for this proposed satellite centre should be within a 50 km radius of Hospital Selayang. The area also should have convenient public transport- in this case easy access to public bus and commuter system and at the fast developing area. The proposal for the location and total cost for the project was agreed by the MAIWP and the Prime Minister Department in October 2011. The building were purchased by MAIWP in October 2011. The Project Brief was prepared by the Hospital Director and the Department of Ophthalmology. The Final Architechtural and Structural Design were done by Engineering Division, Ministry of Health. The tender process were carried out and the project was handed over to the contractor on 15th February 2012 ( Site Possession). The renovation was initially estimated to take about 4 to 6 months durations. 2 weekly progressed meeting were done during the renovation to make sure the work progressed as expected. The physical infrastructure was completed within the estimated time. However, with the installation of new electrical equipments, a new substation electrical supply system needed to be installed to meet the high electricity demand. While the renovation was in progress , the core team (Department of Ophthalmology, the Hospital Management and the Medical Procurement Unit Ministry Of Health), were busy purchasing the equipments. The equipments were only placed in the center once the building is ready to function. As intraocular surgery is performed in this centre, the Operation Threatre (OT) has to be ultraclean with hepar filter inplace and 24 hours airconditioning. The humidity and OT temperature need to be within acceptable reading. Multiple testing were done and the centre was equipped with the temperature detector to allow notification of the problem. To allow the centre to provide the services at maximum capacities, the dedicated supporting staff had been allocated to the centre. The training for staff assisting in cataract surgery was done by the in-house Ophthalmologist and attachment of staff to Day Care Surgery Complex of Hospital Selayang. The project was handed over to Hospital Selayang in October 2012 and the first cataract operation were done on 18/12/2012. The center is planned for official opening by early 2014.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The stakeholders involved in the implementation are as below: A. Ministry Level: 1. Dato Dr Noor Hisham Abdullah (Deputy DG at that time)- as the main person proposing the project. 2. Dato Dr Azmi Shafie- project advisor (Infrastructure, MOH funding and Human Resourse Management) 3. Datin Dr Nor Akma Yusuf (MOH funding and HR management) 4. Datin Dr Asmah Samat (Equipment Purchasing and MOH Funding for operational budget) 5. Ir. Haji Jalal MOH engineering Department - Infrastructure 6. Ir. Haji Suhaimi MOH engineering Department - Infrastructure 7. Ir. Effendi- MOH engineering Department- Infrastructure B. State Level: 8. Dato Dr Azman Abu Bakar- Pengarah Kesihatan Negeri Selangor ( MOH funding and Human Resources Management) C. Hospital Level: 9. Dr Siti Zaleha Mohd Salleh, Director of Hospital Selayang- preparing the Project Brief and overall responsible for the management (staffing, financing and procurement and maintenance). 10. Dr Elias Hussein, Consultant Ophthalmologist and National Ophthalmology Services Head as the main advisor for the design and assist the project management. 11. Dr Nor Fariza Ngah, Consultant Ophthalmologist and Head of Department of the Ophthalmology, Hospital Selayang- Project Manager ( Floor planning and designer) 12. Puan Anis Suhaini- Hospital Selayang Engineering Unit- Project supervisor/engineer Sponsor: 1. Majlis Agama Islam Wilayah Persekutuan (MAIWP) Contractor: 1. Jana Tamia Sdn Bhd Others: 1. Malaysia National Energy (Tenaga Nasional Malaysia) 2. Fire and Rescue Department (Gombak area) 3. Kuala Lumpur City Hall 4. Radicare Services Sdn. Bhd. (Hospital Selayang)
 6. How was the strategy implemented and what resources were mobilized?
The Project was funded by two main bodies via the National Blue Ocean Strategy (NBOS) which were MAIWP (One–off funding) and Ministry of Health Malaysis for operational budget. The infrastructure and in house equipment are funded fully by MAIWP and the operational budgets to run the center for cataract surgery including man power, drugs, disposable, pre and post operative clinic and refraction clinic as well as utilities by Hospital Selayang/Ministry Of Health Malaysia. A. The infrastructure and equipment cost includes: 1. Purchasing of the shop house : RM 2.3 millions a. 4 storey shop house located within 50km from Hospital Selayang (managing centre) with built in elevator. 2. Renovation of the shop house: RM 2.4 millions a. Ground Floor :Two dedicated Operating theatres with ultra clean system for intraocular surgery b. Level 1 : Pre and post operative waiting area and clinical examinations rooms c. Level 2: Pre operative clinic assessment including optometrist rooms and biometry rooms and treatment rooms for pre op investigations. d. Level 3 : Administrative area with pre operative counselling room and Welfare Unit room for assessment of needy patients. e. External facelift of the shop house 3. Equipment can be divided and dedicated into pre operative assessment, cataract surgery and clinics/consultation room: (Total RM 5.176 millions). Examples are: a. Biometry equipments b. Slit lamps c. Fundus camera d. Video teaching slit lamps e. Indirect Ophthalmoscope f. Microscopes ( 2 units) g. Latest model of phacoemulsifications machines ( 2 units) h. Ophthalmic Operating tables i. Microsurgical Ophthalmic Instruments’ and others B. Human resources costs include: estimated per year: RM 1,263,345.20 1. Medical officers 2. Paramedical staff 3. Optometrists 4. Attendances (PPK) 5. Clerical staff C. Consumables and maintenance costs estimated: RM 2,302,631.20 per year 1. Medications 2. Cataract surgery consumables 3. Utility ( water and elctriccity) 4. Maintenance and cleaning services 5. General consumables items

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The MAIWP- Hospital Selayang Cataract Surgery Centre has brought about the following clear benefits: a. A shorter waiting time for cataract surgery which at the present time stands at 2 weeks (compared to a previous waiting time of 4 to 8 months). b. Decongestion at Eye Clinics in the 5 major Specialist Hospitals in State of Selangor c. A speedier turnaround time for patients undergoing cataract surgery d. An increased output for cataract surgery done in the state of Selangor. To date a total of 1,500 cataract surgeries have been carried out in less than eleven months of full operation e. A complete Day care Cataract surgery facilities- convenient and at affordable cost.

 8. What were the most successful outputs and why was the initiative effective?
a. The centre is using the E- Management Surgical System dedicated and caters for Cataract surgery. The Electronic Medical Records were designed to be able to interface directly with the National Eye Database: Cataract Surgery Registry (CSR). This will allow also information required for the Registry i.e. automatically transferred to the Registry with entry only. The CSR also allow the cataract surgery done by each surgeon to be documented and projected via the CUSUM system (A Dynamic Tool for Monitoring Competency in Cataract Surgery Performance ). This CUSUM finding will be reviewed by the Head of Opthalmology, Selayang Hospital for the monitoring of the cataract surgery done by each surgeon. Any recurrent complications will be shown and necessary action will be taken by the Head after the discussion with the Department Management Meeting that is held at least one a month in Selayang Hospital. b. To ensure ultra clean Operating Room (OR) and stability of the OR- a system (ASCADA) is installed to monitor the OR temperature and humidity. The system will alert and notified the on call staff and immediate response should be done by the Hospital Support Service (Radicare Sdn. Bhd.) If the condition is not able to be fixed within time, patients will be informed of the OR cancellation by the clerical staff and case will be scheduled in the next available operating day.

 9. What were the main obstacles encountered and how were they overcome?
There were few main obstacles encountered during and after the implementation of the projects. i. During the implementation: Delay in project completion Obstacles Troubleshooting 1. To get the ultra-clean operation theatre for intraocular operation which fulfil the Private Health Facilities Act at the standalone premises outside the hospital area. Strict requirement for the contractor to fulfil with the support of the Engineering Division, Ministry of Health. 2. Instability of electrical supply to support the high demand of the center- 24 hours air-conditioning for the equipment care. New electrical power substation dedicated for the power supply to the center was constructed by Malaysia National Energy (Tenaga Nasional Malaysia). The cost for the substation was within the budget allocated. ii) Post - implementation : Obstacles Troubleshooting 1. Inadequate number of Optometrist Rotational basis from all main Hospital with Optometrist within Selangor and Putrajaya until the permanent post for Optometrist approved by central agency and placed at the Cataract Operation Centre. 2. Not enough surgeon - as the operations are only to be done by the qualified surgeon - there are not enough surgeons to rotate for the OT days Similarly all the Main Hospital in Selangor (5) together with 2 from Federal Territory has agreed to join the rotation. However, this center is not operating at the maximal capacity yet but the total number of cataract operation that has been performed are almost one third of the total number of cataract surgery done within Selangor Ophthalmology Departments. 3. No dedicated vehicle / transport to bring the medication, consumables, operation items and food ration for patients to the center from Hospital Selayang on regular basis. Scheduling of existing hospital transportation has been done to over come those problems as temporary measures. Purchasing of center own transport to ensure the smooth running of the centeris the best option. The Multi-Purpose Vehicle (MPV) is bought using the similar fund with the approval from the MAIWP and MOH. 4. Fresh paramedic staff with no ophthalmic operation and clinic experience Training of staff done by the Daycare staff of Hospital Selayang and Ophthalmologists for a period of at least 4 - 6 months attachment and they are privileged to assist the surgery

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The key benefits in the delivery of public services resulting from this initiative include: 1. Speedy waiting time for cataract surgery in State of Selangor as well as the Federal Territory (Wilayah Persekutuan Kuala Lumpur and Putrajaya) as we accept all referrals that fulfil the day care surgery procedure. 2. Convenience; as this the one stop cataract centre whereby all the pre-operative assessment including blood investigations, echocardiography analysis and biometry using the best of biometry method available as well as pre-op refraction, followed by post operation care and assessment for the patients. Patients will only require at least 2 visits - pre operatively then 2 visit after the operation. Those with no medical illness will be completely discharged from the system and those with medical illness especially diabetic retinopathy will be sent for further regular follow up at the Health Facilities nearest to their homes. 3. Decongestion of the Major Specialist Hospitals as majority of cases coming for surgery are still for cataract which is our main bread and butter services even in subspecialty Hospitals. 4. Day Care Surgical Centre - most of the patients are fit for day care surgery and majority of them prefer day care surgery to hospital admission or hospitalisation. Staggered time will be given to the patient to ensure minimal waiting time at the centre. Light meal will be served as well. 5. Low cost surgery centre: as this is the public services facilities the cost for the surgery are very minimal as it is subsidised. For non government personnel the cost for surgery is only RM 103.00 and those senior citizen (aged 60 and above) will be given 50% discount. Patients with government guarantee letter, there will be no surgery fee charges. 6. However patient still needs to pay the intraocular lens if they are non government sponsor. For patients who cannot afford to buy the intraocular lens the National IOL (intraocular lens) is always available to assist them. The Medical Social Workers of Hospital Selayang will assist the needy patients to get fund from Baitulmal Selangor, Lembaga Zakat Selangor and Tabung Bantuan Kebajikan Perubatan Cawangan Hospital Selayang. Local banking sectors also sponsor lens to the needy poor patient as part of their corporate social responsibility (CSR). 7. The facilities available in the centre offer the latest of cataract surgery technology. In fact, it is with pride to note that it offers quality surgery performed by qualified surgeons at a much lower cost. 8. The centre was built with the electronic management system and is directly connected to the National Cataract Registry Database. The total number of surgeries, the surgeon, any complications, and the best corrected vision after the last visit all are available on line and in the system. 9. The waiting time for the surgery and number of cataract surgeries performed per day also can be monitored by the manager. 10. Improve quality of life for patients as their impaired vision are back to normal.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
This initiative is sustainable as this is an NBOS project (National Blue Ocean Strategy) i,e involvement and commitment of MAIWP and our very own Ministry of Health (MOH). As per agreement and understanding, MAIWP has given the one off fund for the procurement of the building and its renovation and equipped the center with the latest technology for functional cataract day care services as long as Hospital Selayang/Ministry of Health chooses to use this facility. For the maintenance of the building and operational budget including the staffing, all are coming from MOH. As this is purely public service department, we are also receiving donation from other ‘generous’ NGO for purchasing of intraocular lens for those we cannot afford to buy in their own. This project is the first project (pilot project) as such in Malaysia, but many other NGO are looking into the success of this project to replicate the center in other state such as Melaka and Kelantan. Besides daycare surgery center for cataract, MOH is looking into possible other daycare surgery center - for example orthopedic day surgery as well as psychiatric rehabilitation /behaviour modification community center.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
i. Nothing is impossible - is the word that best explained our experience in preparing this project, walking through the 9 months construction works and many coordination meetings to ensure the success of this project. ii. Training of untrained and inexperience paramedic to become the best and competent cataract surgery assistance is a great challenge. iii. Hard work, good team work and unlimited commitment and support from all parties were the main reasons for the success of this centre. iv. For future projects,a bigger building or landed property is required to ensure adequate space to cater for more OT. v. The get the well experienced contractor to do the specialized area like the Operation Theatre as it is an ultra clean operating room. vi. To properly plan the center; there should be no hurry to complete or rush for the dateline; as the most important factor is to make ready a well functioning facility

Contact Information

Institution Name:   Cataract Surgery Centre Islamic Affair C
Institution Type:   Government Agency  
Contact Person:   Siti Zaleha Mohd Salleh
Title:   Dr.  
Telephone/ Fax:   +603-61263333 / 03-61205220
Institution's / Project's Website:  
Address:   No. 11 Jalan 3/3C, Sri Utara off Jalan Ipoh
Postal Code:   68100
State/Province:   KUALA LUMPUR

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