PAIN FREE PROGRAM

MANUAL

2 ND EDITION

MEDICAL CARE QUALITY SECTION

MINISTRY OF HEALTH MALAYSIA
 Pain Free Program Manual 2018: 2nd Edition

This document was developed by the Clinical Audit Unit, Medical Care Quality Section of
Medical Development Division, Ministry of Health Malaysia and the National Pain Free
Program Committee.

Published in September 2018

A catalogue record of this document is available from the National Library of Malaysia

ISBN: 978-967-2173-32-8

A copy of this document is also available at MOH Portal: www.moh.gov.my

Copyright © Ministry of Health Malaysia.

All rights reserved. No part of this publication may be reproduced or distributed in any
form or by any means or stored in a database or retrieval system without prior written
permission from the Ministry of Health Malaysia.
 FOREWORD
Pain, whether it is acute or chronic pain, is a common symptom experienced by patients.
Pain may lead to a lot of suffering and it affects their recovery from their illness either
directly or indirectly. The MOH is aware of the challenges of improving the pain
management in our healthcare facilities. Hence, in 2008, the MOH initiated the “Pain As
The 5th Vital Sign” (P5VS) initiative. This initiative was followed by the “Pain Free
Hospital” concept in 2011. “The Pain Free Hospital” concept emphasized on holistic pain
management by using a multidisciplinary team approach that include Anaesthesia and
Analgesia, Modern Surgical Techniques, and Traditional and Complementary Medicine.
“Pain Free Hospital” was piloted in 3 hospitals namely Hospital Raja Permaisuri Bainun Ipoh, Hospital Selayang
and Hospital Putrajaya. To date, there are 16 hospitals and 1 institution that have been certified with the Pain Free
Hospital status.
As the Pain Free Program grew, the P5VS initiative has been expanded to the Public Health Program and Oral
Health Program. In 2016, Public Health Program started their P5VS as part of their pain management in the Health
Clinic and Oral Health begin theirs the P5VS in 2018. Through this Pain Free Program, close collaboration with
Pharmacy Services Program has been established. This remarkable achievement of pain management through the
involvement of other Programs prove that the MOH is committed to ensuring the best quality of care is delivered.
The publication of this Manual will become an important resource for our healthcare facilities. Commitment and
dedication of the healthcare providers are essential in ensuring the success and sustainability of this Pain Free
Program. I sincerely hope that we will be able to provide the “pain free” experience to our patients.

Dato’ Dr. Azman bin Abu Bakar

Deputy Director-General of Health (Medical)
Ministry of Health Malaysia,
September 2018

PREFACE
Pain Free Program was initially known as Pain Free Hospital initiative. It was first
launched in 2011. The focus was for improvement of pain management using a holistic
approach in hospital service especially on the management of acute pain. In year 2016,
twelve government hospitals certified as ‘Pain Free Hospital’ status and in 2017, the three
pioneer hospitals were re-certified. The Pain Free Hospital (PFH) initiative was well
recognized by our Malaysian Government and aimed to have all hospital with specialist
to certify as PFH in year 2020. PFH program has attract attentions of our healthcare
providers in the community. In 2017, the ideas expanded to the other Programs in the
Ministry of Health (MOH), which known as Pain Free Program (PFP).
Pain Free Program will be implemented in two ways; PFH for all hospital with specialist, and Pain as 5th vital
sign for hospital without specialist including other MOH healthcare facilities. This new edition of Pain Free
Program Manual is to meet the needs of the services mentioned. In this new manual, a more comprehensive
guideline in regards of the certification process has been elaborate. We have revised the audit question, surveys
question and marking scheme. We are trying to be more focus on the basic concept of implementation of the P5VS
and assess all aspect of objective in PFP where applicable. The usage of this manual will reward user with four
years certification.
Lastly, I would like to thanks my PFP committees in their supports and patient throughout the process of
producing this 2nd Edition Pain Free Hospital Manual.

Dr. Ungku Kamariah binti Ungku Ahmad

Chairman,
National Pain Free Program Committee
September 2018
 CONTRIBUTORS

1. Dr. Ungku Kamariah Ungku Ahmad

2. Dr. Kavitha Bhojwani
3. Dr. Aminuddin Ahmad
4. Dr. Harijah Wahidin
5. Dr. Muralitharan Perumal
6. Dr. Wan Azzlan Wan Ismail
7. Dr. Paa Mohamed Nazir Abdul Rahman
8. Dr. Faizah Muhamad Zin
9. Dr. Anith Syazwani Adnan

ACKNOWLEDGEMENT

1. National Pain Free Committee Member

2. Medical Care Quality Section MOH
 1

CONTENT
No. Topic Page
1. INTRODUCTION 4-7
1.1. BACKGROUND 4-5
1.2. CONCEPTS 6-7
1.3. OBJECTIVES OF PAIN FREE PROGRAMS 7
2. POLICY STATEMENT ON PAIN
8
ASSESSMENT AND MANAGEMENT
3. PATIENT CHARTER (PIAGAM PELANGGAN) 9
4. CRITERIA FOR PAIN FREE HEALTH CARE
10
FACILITIES (HOSPITAL/CLINIC)
4.1. CRITERIA CHECKLIST FOR PAIN FREE
HEALTH CARE FACILITIES 11-17
ACCREDITATION
5. PAIN FREE PROGRAM COMMITTEE 18-21
5.1. HOSPITAL WITH SPECIALIST 18
5.2. HOSPITAL WITH-OUT SPECIALIST 19
5.3. PUBLIC HEALTH FACILITY 20
5.4. DENTAL HEALTH FACILITY 21
6. DUTIES AND RESPOSIBILITES OF PFP
22-33
COMMITTEE
6.1. GENERAL DUTIES 22
6.2. THE DUTIES AND RESPONSIBILITY OF
22-33
SPECIFIC UNITS
6.2.1. PRIMARY UNIT 22-24
6.2.2. ACUTE PAIN SERVICE TEAM (APS) 24-25
6.2.3. OBSTETRIC ANALGESIA TEAM 25-26
6.2.4. PHARMACISTS 26-31
6.2.5. PHYSIOTHERAPISTS 31
6.2.6. OCCUPATIONAL THERAPIST 32
 2

6.2.7. T/CM TEAM 32-33

7. TRAINING & EDUCATION 34
7.1. TRAINING OF HEALTH CARE FACILITIES
34
STAFF
7.2. PATIENT EDUCATION 34
8. IMPLEMENTATION 35-36
8.1. SUGGESTED PAIN FREE PROGRAM
35
CERTIFICATION GANTZ CHART
8.2. SUGGESTED IMPLEMENTATION TIMELINE 36
9. MULTIDISCIPLINARY APPROACH 37
10. PAIN FREE CERTIFICATION 38-62
10.1. PAIN FREE CERTIFICATION FLOWCHART 38
10.2. CERTIFICATION AUTHORITY 39-41
10.3. CERTIFICATION PROCESS 42-44
10.4. CERTIFICATION 45-46
10.5. PERIODIC REPORTS 46
10.6. BEST PRACTICE IN CERTIFICATION
46
PROCESS
10.7. THE CONDUCT OF A CERTIFICATION VISIT 47-56
10.8. GUIDELINES FOR WRITING A
56-62
CERTIFICATION REPORT
11. RESOURCE MATERIAL 62-63
12. APPENDIXES: 64-83
12.1. APPENDIX 1:
BORANG AUDIT PERLAKSANAAN
64-65
PAIN 5TH VITAL SIGN NURSING & AMO
AUDIT FORM
12.2. APPENDIX 2:
BORANG AUDIT PELAKSANAAN PAIN AS
THE FIFTH VITAL SIGN (P5VS) OLEH
66-67
DOKTOR (30% daripada jumlah katil yang
diwartakan)
 3

12.3. APPENDIX 3: BORANG SOAL SELIDIK

68
PESAKIT
12.4. APPENDIX 4:
PAIN AS THE FIFTH VITAL SIGN: STAFF 69-70
SURVEY
12.5. APPENDIX 5:
LAPORAN TAHUNAN PELAKSANAAN TAHAP
KESAKITAN SEBAGAI TANDA VITAL KELIMA 71-73
(PEKELILING KPK BIL.9/2008) &
HOSPITAL/ KLINIK BEBAS KESAKITAN
12.6. APPENDIX 6:
APPLICATION FORM FOR PAIN FREE 74
HEALTH CARE FACILITIES SURVEY
12.7. APPENDIX 7:
SUGGESTED SCHEDULE OF 75
CERTIFICATION VISIT
12.8. APPENDIX 8:
MEDICATION HISTORY ASSESSMENT 76
FORM CP1
12.9. APPENDIX 9:
PHARMACOTHERAPY CP2 ( FOR IT 77-78
HOSPITAL)
12.10. APPENDIX 10:
PHARMACOTHERAPY CP2 ( FOR NON-IT 79-81
HOSPITAL)
12.11. APPENDIX 11:
82-83
NOTA RUJUKAN PESAKIT CP4
 4

1. INTRODUCTION
1.1 BACKGROUND
1.1.1. Pain is one of the main reasons why patients are
admitted to hospital and unrelieved pain is the
reason why patients fear going to hospital, especially
for surgery or other painful procedures.
1.1.2. Pain is generally considered unavoidable.
However, with modern drugs and techniques,
there are many simple ways of relieving pain.
Unfortunately, pain is often not well managed in
hospitals.
1.1.3. Some of the reasons for poor pain management
include:
 Pain relief is not considered a priority in medical
practice.
 Medical staff often lacks sufficient knowledge
about pain and pain management.
 There are still many barriers to the use of opioid
analgesics.
1.1.4. Initiatives to improve pain management have
been started in many countries over many years.
In Malaysia, Pain as the 5th Vital Sign was
implemented in stages in MOH hospitals from
2008, and subsequently implemented in
University hospitals and several private hospitals.
1.1.5. The Declaration of Montreal, made at the
International Pain Summit in 2010, states that
“Access to Pain Management is a basic human right”
1.1.6. Policies and procedures for pain assessment and
management is now a requirement for MSQH and
JCI accreditation.
1.1.7. Implementing the concept of Pain Free Program
has many benefits and promotes the concept of
“patient centered care” based on effective
integration and optimal utilization of existing
services.
 5

1.1.8. Specific benefits for the patient:

 More comfortable and shorter hospital stay (or
day stay only).
 Less risk of nosocomial infection.
 Decreased anxiety and stress.
1.1.9. Benefits for the hospital:
 Better customer satisfaction
 Optimal use of Ambulatory Care Centers by
promoting the use of day surgery and
minimally invasive surgery.
 6

1.2 CONCEPTS

The main components of PFH are shown in

the diagram below:

Anesthesia &
Analgesia

PAIN FREE
PROGRAM
Traditional &
Modern
Complementary
Surgical
Medicine
Techniques

Anesthesia and Analgesia:

Promoting the use of regional anesthesia and establishment of
protocols for treatment of different types of acute pain.

Modern Surgical Techniques:

Promoting the use of Minimally Invasive Surgery (MIS) and
Day Care Surgery (DCS) with excellent pain control.

Traditional and Complementary medicine (T/CM):

Promoting the incorporation of non-pharmacological
techniques including T/CM techniques (e.g. massage,
acupuncture, deep breathing/relaxation) into pain
management for all patients.
 7

A Pain Free Program will have the following

features:
i. Implementing Pain as 5th Vital Sign:
• Ensure standards for pain assessment
• Recognize and treat pain promptly
• Ensure information about pain relief is available to
all patients
• Promise patients’ attentive analgesic care
• Policies for use of advanced technologies
• Monitor adherence to standards
ii. Promoting the use of Minimally invasive surgery
(MIS) – smaller wounds means less pain.
iii. Encourage day care surgery - provides safe and
effective peri operative analgesia as well as post-
operative monitoring and follow up of patients after
discharge.
iv. Standardized protocols for analgesia for different
types of acute pain.
v. Promoting increased use of regional anaesthesia
for peri-operative pain relief.
vi. Integration of Traditional & Complementary
medicine and promoting non-pharmacological
techniques for pain relief and relief of side-effects of
analgesics.

1.3 OBJECTIVES OF PAIN FREE PROGRAMS

i. Pain free surgery

ii. Pain free labour

iii. Pain free procedures

iv. Pain free rehabilitation

v. Pain free discharge

 8

2. POLICY STATEMENT ON PAIN FREE

PROGRAM
2.1. Pain is one of the Vital Signs.

2.2. Pain is assessed in all patients.

2.3. Standardized pain assessment tools must be applied

consistently.

2.4. Healthcare providers should listen and respond

promptly to patient’s report of pain and manage pain
appropriately.

2.5. Healthcare facility staff should be continually educated

& aware about pain assessment & management.
 9

3. PATIENT CHARTER (PIAGAM PELANGGAN)

This health care facility will endeavour to provide you with a
pain free experience.
We pledge to treat pain from all conditions including pain
from acute medical conditions, surgery, trauma, cancer and
labour.
Your pain will be given prompt attention and managed
within one hour.
All patients with pain will be assessed and treated by
trained professionals; for those with acute pain conditions,
we aim to achieve a pain score of less than 4.
Pain control will be individually tailored using appropriate
medications as well as non-pharmacological methods
including traditional and complementary medicine.
Our health care professionals will enquire about your pain
and care for your comfort throughout your health care
facilities stay.
********************************
Fasiliti kesihatan ini akan memastikan anda bebas daripada
kesakitan.
Kami berjanji akan merawat semua keadaan kesakitan
termasuk yang berpunca dari penyakit akut perubatan,
pembedahan, trauma, kanser dan sakit bersalin.
Kesakitan anda akan diberi perhatian segera dan dirawat
dalam masa satu jam.
Semua pesakit yang mengalami kesakitan akan dinilai dan
dirawat oleh kakitangan profesional terlatih; bagi kesakitan
akut, matlamat kami adalah untuk mencapai tahap
kesakitan kurang daripada 4.
Pengurusan kesakitan akan diberi secara individu dengan
menggunakan kaedah pemberian ubat dan bukan ubat,
termasuk perubatan tradisional dan komplementari.
Warga profesional kesihatan akan sentiasa memantau tahap
kesakitan dan keselesaan anda semasa berada di fasiliti-
fasiliti kesihatan
5
 10

4. CRITERIA FOR PAIN FREE HEALTH CARE

FACILITIES (HOSPITAL/CLINIC)

All health care facilities are required to have the

following:

Mandatory:
 A written policy on pain free program
 Implement Pain as the 5th Vital Sign
 Practice standardized treatment protocols for
management of acute pain
 Conduct training for all health care staff on
knowledge and skills in pain assessment and
management
 Educate patients and get them actively involved
in their own pain management
 Carry out regular audit of pain assessment
and management practices and outcomes
 Use multi-disciplinary team approach in pain
management
 Incorporate non-pharmacological technique
into pain management practices

Optional:

 Have a policy and guidelines on Minimally Invasive

Surgery
 Have a policy and guidelines on Day Care Surgery
 Incorporate T/CM into pain
management practices
 11

4.1. CRITERIA CHECKLIST FOR PAIN FREE HEALTH

CARE FACILITIES ACCREDITATION

Criteria Assessment checklist Comments Marks

Criteria 1: 1.1. P F P Policy An adapted PFP

incorporated into policy is available
A written policy at Quality unit, all
health care 4
on pain free
facility’s policies wards and all
program
(MANDATORY) departments.
a. Specialist
Hospital 1.2. Client Charter Must be displayed
b. Hospital on Pain in all patients’
2
without management contact areas e.g.
specialist. ED, clinics, wards.
c. Health Clinic 1.3 PFP committee: Documented
 members from all evidence in PFP
disciplines (refer file:
KKM.600-  List of PFP
28/2/10JLD committee
3
2(43)) members
 Minutes of
 meetings meetings
(minimum twice a  Attendance
year) list
Criteria 2: 2.1 Pain score Patient pain
charted in the vital orientation done.
Implement Pain signs observation
as form (electronic or Pain scores must
the 5th Vital paper). be documented as 3
Sign (P5VS)
for all other vital
a. Specialist signs and at
Hospital reassessment
b. Hospital
without 2.2 Flow charts for Flowcharts must
specialist P5VS (Doctors and be displayed
Paramedics) are (either on wall or
c. Health Clinic 4
available in all in specified place
wards or clinics. e.g. folder in pain
free corner)
 12

4.1 CRITERIA CHECKLIST FOR PAIN FREE HEALTH

CARE FACILITIES ACCREDITATION

Criteria Assessment checklist Comments Marks

2.3 Paramedics Paramedics should

know about the know about the
policy that Pain is policy that Pain is
the 5th Vital Sign the 5the Vital Sign. 3
in all clinical areas. Any Paramedics
can be asked
about this policy.

2.4 Pain scoring is Ask patient if staff

correctly done. have asked them
4
about their pain
*assess together
with criteria 5.2 and pain score

3.1 Acute Pain Protocols must be

Criteria 3: Protocols for available in Acute
Standardized management of Pain folder. Acute
treatment acute pain is Pain Management
protocols for 3
available Handbook should
management of be available for
acute pain easy reference in
Criteria 3.1 and all clinical areas.
3.2:
3.2 Analgesic Analgesic ladder
a. Specialist
ladder for acute should be easily
Hospital
pain management accessible in all
b. Hospital
is available in all wards a n d
without
wards/clinics. c l i n i c s (e.g. as
specialist 3
(T&CM clinic not poster on the wall
c. Public applicable) or in drug charts
Hospital or elsewhere, e.g.
Criteria 3.3: in folder in pain
d. Specialist free corner).
Hospital
3.3 Regional Data and records on
A nesthesia is used RA implementation
2
as part of post-op should be available.
pain management.
 13

4.1 CRITERIA CHECKLIST FOR PAIN FREE HEALTH

CARE FACILITIES ACCREDITATION

Criteria Assessment checklist Comments Marks

Criteria 4: 4.1 Regular P5VS Data and records on

Train all training for trainings conducted
healthcare staff doctors, nurses, for each category of
on knowledge AMO, other allied staff should be
and skills in health staffs. available. (CME,
pain assessment CNE, TOT, Seminars
and and workshops) 4
management Target: at least 60%
a. Specialist of all staff should be
Hospital trained within past
b. Hospital 3 years (excludes
without PPK and drivers).
specialist
c. Health Clinic 4.2 Regular Acute Data and records on
Pain Management the Acute Pain
courses for nurses, Management
AMO and doctors. courses conducted
4
and number of
doctors, AMO and
nurses trained in
Acute Pain should
be available.

Criteria 5: 5.1 Patient Should be available

Patient information at all patient’s
education and sheets/posters, contact areas (eg.
involvement in videos and other ED, clinics, wards 4
their pain educational etc).
management material.
a. Specialist
Hospital
5.2 Patient Any patient or care
b. Hospital
without feedback on pain giver can be asked if
specialist score, treatment they have been
options and their educated about pain 6
c. Health Clinic rights. and pain
management
techniques.
 14

4.1 CRITERIA CHECKLIST FOR PAIN FREE HEALTH

CARE FACILITIES ACCREDITATION

Criteria Assessment checklist Comments Marks

Criteria 6: 6.1 PFP audit and Data collected and
Regular audits survey data on analyzed on yearly
on pain doctors, nurses, basis and records
assessment and AMO, allied of all audit(s) are
management health, available,
pharmacist and including results
a. Specialist
Hospital patient (Refer and follow-up
appendix 1, actions
b. Hospital appendix 2 & 4
without  Patients
appendix 5
specialist survey (≥80%)
c. Health Clinic  Staff survey
(≥80%)
 Doctors’ audit
(≥80%)
 NNA (≥85%)

6.2 Review of pain Doctors’ clinical

management by practice
doctors.
 Knowledge
 Technique of 10
assessment
 Documentation
 Management

Criteria 7: 7.1 MOH (or Should be available

Hospital adapted) in hospital policy
Policy and
policy on MIS and surgical-based
guidelines on
disciplines
Minimally 3
departments policy.
invasive surgery
a. Specialist
Hospital only
 15

4.1 CRITERIA CHECKLIST FOR PAIN FREE HEALTH

CARE FACILITIES ACCREDITATION
Assessment
Criteria checklist Comments Marks

7.2 Training, Evidence:

credentialing and File C&P for MIS
privileging (C&P) with list of
3
surgeons
of surgeons in
privileged with
MIS.
MIS procedures

7.3 Data on MIS Data and records on

MIS procedures for
3
different discipline
are available.

Criteria 8: 8.1 MOH policy Should be available

Policy and on Day Care in surgical-based
guidelines on Surgery departments.
Day Care available (Mandatory)
Surgery  Operation
Theater
a. Specialist 3
Hospital only  Anesthesia
Clinic
 Surgical Base
Department
 Wards& clinic

8.2 Day Surgery Data of cases

data of cases should be available
under General (hospital wide
Anesthesia target ≥ 20%).
 16

4.1 CRITERIA CHECKLIST FOR PAIN FREE HEALTH

CARE FACILITIES ACCREDITATION
Assessment
Criteria checklist Comments Marks
Minimal
Requirement:
% score
0 0
≤5 1
≤10 2
≤15 3
5
≤20 4
>20 5

(5 marks) – average
of all department

Criteria 9: 9.1Evidence Patients’ records

indicating managed by APS
Multidisciplinary
multidisciplinary team,
team approach
management physiotherapists, 4
in pain
of patient: pharmacists, other
management
 Pre-operative/ disciplines by
(Refer page 37) referral.
non-surgical/
a. Specialist medical
Hospital Data and records
patients
of
b. Hospital  Post-operative
without Multidisciplinary
4
specialist patients ward rounds or
case discussions.
c. Health Clinic
 17

4.1 CRITERIA CHECKLIST FOR PAIN FREE HEALTH CARE

FACILITIES ACCREDITATION
Assessment
Criteria checklist Comments Marks
Criteria 10: List of types of non- Information and
Incorporate pharmacological evidence of types
non- methods and or of non-
pharmacological application pharmacological
and T/CM into of T/CM methods in techniques used.
pain pain management.  Data and
management records of cases
practices (e.g. massage,
a. Specialist acupuncture,) 10
Hospital  Written
b. Hospital evidence in
without nursing report
specialist  Physiotherapist,
Occupational
c. Health Clinic
Therapist report
 T&CM referral
and report
 18

5. PAIN FREE PROGRAM (PFP)

COMMITTEE MEMBERS
5.1 HOSPITAL WITH SPECIALIST
POSITION

Chairman Hospital Director

Deputy Chairman 1 Surgeon

Deputy Chairman 2 Anaesthesiologist

Anaesthesiologist

All Surgical Disciplines

O&G Specialist

Paediatrician

Physicians

Emergency physicians

Specialists from other disciplines

Matron/Hospital Supervisor

Sisters/AMO from selected

disciplines
APS Sister or staff nurses

Pharmacist

T/CM practitioner (where

available)
Physiotherapist

Occupational therapist

Education officer
 19

5.2 HOSPITAL WITH-OUT SPECIALIST

POSITION

Chairman Hospital Director

Deputy Chairman 1 Senior MO 1

Deputy Chairman 2 Senior MO 2

MO

Matron / Hospital supervisor

Sisters

Nurses

AMO

Pharmacist

Physiotherapist

Occupational Therapist

Health Education Officer

 20

5.3 PUBLIC HEALTH FACILITY

POSITION

Chairman District Health Officer

Deputy Chairman 1 FMS

Deputy Chairman 2 FMS

MO
Matron

Sister

Nurses

AMO

Pharmacist

Physiotherapist

OCCT
 21

5.4 DENTAL HEALTH FACILITY

POSITION

Chairman Dental Health Officer

Deputy Chairman 1 Dental Specialist

Deputy Chairman 2 Dental Officer

Matron
Sister

Nurses

Pharmacist

Physiotherapist ( if available)

OCCT( if available)

TCM Medical Officer ( if available)

 22

6. DUTIES AND RESPOSIBILITES OF PFP

COMMITTEE
6.1 General duties:
6.1.1 Coordinate and conduct Training for Pain as 5th
Vital Sign for nurses and doctors.
6.1.2 Monitoring of implementation of P5VS in wards
e.g. by nursing audit.
6.1.3 Monitoring of Day Care Surgery: numbers and
quality (phone call to patient at home)
6.1.4 Monitoring of MIS:
 Number of surgeons trained
 Number of procedure performed per year
6.1.5 Overseeing the formation of Multidisciplinary
teams to do clinical round (e.g APS team + surgical
team + physiotherapist + pharmacist to a round
once a month) or multidisciplinary discussion on
selected patient once or twice a month.
6.1.6 Monitoring of non-pharmacological techniques
and T/CM (when applicable) for pain
management.
6.1.7 Monitoring the use of regional anesthesia for post-
operative pain management.
6.1.8 Conducting training workshops on non-
pharmacological methods for pain management.
6.1.9 Patients educations activities – information sheets,
public talks and exhibition, Medic TV.

6.2 The duties and responsibility of specific

units:
6.2.1. Primary Unit
6.2.1.1. General Duties
6.2.1.1.1. To be a member of multidisciplinary team.
6.2.1.1.2. To contribute & facilitate in all activities
 23

related to the implementation of the Pain

Free Health care facilities concept.
6.2.1.1.3. To promote other non-pharmacological
techniques of pain management including
physiotherapy, deep breathing/relaxation
and T/CM.
6.2.1.1.4. To help in developing awareness, training
and education of health care facilities staff
in managing acute pain: use of the analgesic
ladder and morphine pain protocol for
pain management.
6.2.1.1.5. To ensure adherence to the standard
protocols in pain management.
6.2.1.1.6. To implement standard monitoring for
patients, including Pain Score and Sedation
score.
6.2.1.1.7. To participate in patient education
regarding pain management.
6.2.1.1.8. To assist in continuing evaluation and audit
of pain management in the wards.

6.2.1.1.9. To assist and facilitate clinical research in

pain management.

6.2.1.2. Additional for Surgical Based Disciplines

6.2.1.2.1. To identify patients suitable for Day Care
surgery
6.2.1.2.2. To ensure adherence to the guidelines &
protocols for Day Care surgery.
6.2.1.2.3. To provide training for minimally invasive
surgery.
6.2.1.2.4. To explain to patients about Day Care
surgery & minimally invasive surgery
6.2.1.2.5. To perform continuing evaluation and
audit of day care surgery & minimally
invasive surgery
 24

6.2.1.2.6. To conduct and facilitate clinical research

on minimally invasive surgery
6.2.1.2.7. To develop awareness, train and educate
health care facilities staff in minimally
invasive surgery
6.2.1.2.8. To promote the development of new
surgical/minimally invasive
techniques for day care surgery
6.2.1.2.9. To improve and facilitate in the assessment
and management of pain in the post-
operative patients including those after day
care surgery.

6.2.1.3. Additional for Non-Surgical Disciplines:

To improve the management of non-surgical
acute pain.

6.2.2. ACUTE PAIN SERVICE TEAM (APS)

6.2.2.1. To be a member of multidisciplinary team.
6.2.2.2. To conduct a proper recruitment,
assessment and follow-up for APS patients
by providing adequate resources (staff,
facility and equipment) in managing pain.
6.2.2.3. To liaise with other clinical departments
and other healthcare groups (including
T/CM and palliative medicine) in order
to provide an individualized,
multidisciplinary approach to the
management of pain for every patient who
needs it.
6.2.2.4. To develop awareness, train and educate
health care facilities staffs in managing
acute pain: use of analgesic ladder and
morphine pain protocol for pain
management
6.2.2.5. To develop, improve and implement
 25

standardized protocols in various

techniques of pain management
6.2.2.6. To implement standard monitoring for
patients including:
 Pain Score
 Sedation score (with opioid use).
 Other vital signs.
6.2.2.7. To liaise with other disciplines in educating
patients about pain management.
6.2.2.8. To perform continuing evaluation and audit of
pain management services.
6.2.2.9. To conduct and facilitate clinical research in
pain management.
6.2.2.10. To promote the development of new analgesic
techniques in pain management e.g. regional
anaesthesia technique.

6.2.3. OBSTETRIC ANALGESIA TEAM:

6.2.3.1. To be a member of the multidisciplinary team.
6.2.3.2. To provide safe and effective labour analgesia
using simple technique including non-
pharmacology approaches (e.g.
physiotherapy, TENS, massage, T/CM).
6.2.3.3. To coordinate the team of healthcare
providers who are involved in providing peri-
partum analgesia.
6.2.3.4. To provide 24-hour obstetric analgesia
service whenever possible.
6.2.3.5. To promote teamwork between the
anaesthesiology and obstetric teams.
6.2.3.6. To improve post-partum analgesia in the
ward.
6.2.3.7. To participate in patient’s education on peri-
partum pain relief.
 26

6.2.3.8. To provide continuing medical education on

the principles and practice of obstetric
analgesia.
6.2.3.9. To conduct audit of obstetric analgesia
services.
6.2.3.10. To conduct clinical research in obstetric
analgesia services.
6.2.3.11. To contribute & facilitate in all activities
related to the implementation\of Pain Free
Health care facilities concept.

6.2.4. PHARMACISTS
Good Pharmacy Practice (GPP) is the very essence
of pharmacy profession and it expresses
pharmacists’ covenant with the patients not only
to ‘do no harm’, but also to facilitate good
therapeutic outcomes with medicines. In order to
rationalize this, the roles of pharmacists in Pain
Free Health care facilities must be in line with the
standards of pharmacy services and in accordance
to the ‘Joint International Pharmaceutical
Federation (FIP) and World Health Organization
(WHO) Guidelines on GPP. It is recommended that
any health care facilities that are taking up the
Pain Free Health care facilities concept consider
the following roles and activities for pharmacists
with regards to medications used in pain
management, where appropriate:

6.2.4.1. Obtain, store, secure, distribute & dispense

6.2.4.1.1. To obtain, store and secure medicine

preparations and medical products from
the list of health care facilities formulary.
6.2.4.1.1.1. Pharmacists who are responsible for
procurement should ensure that the
procurement process is transparent,
professional and ethical so as to
 27

promote equity and access, and to

ensure accountability to relevant
governing and legal entities.
6.2.4.1.1.2. Pharmacists should ensure stock
availability and adequacy as well as
establish contingency plans for
shortages of medicines and for
purchases in emergencies.
6.2.4.1.1.3. Pharmacists should assure that proper
storage conditions are provided for all
medicines, especially for controlled
substances, used in the health care
facilities.
6.2.4.1.2. To distribute medicinal preparations and
products.
6.2.4.1.2.1. Pharmacists should ensure that all
medicinal products are handled and
distributed in a manner that assures
reliability and safety of the medicine
supply by establishing an effective
distribution system.
6.2.4.1.3. To prepare & dispense medicinal products.

6.2.4.1.3.1. Pharmacists should screen all

prescriptions received, considering the
therapeutic, social, economic and legal
aspects of the prescribed indication (s),
before supplying medicinal products to
the patients.
6.2.4.1.3.2. Pharmacists should ensure that
compounded medicines are consistently
prepared to comply with written
formula and quality standards for raw
materials, equipment and preparation
processes, including sterility where
appropriate.
6.2.4.1.3.3. Pharmacists should provide advice to
ensure that the patients receive and
understand sufficient written and verbal
 28

information to derive maximum benefit

for the treatment.
6.2.4.1.3.4. Pharmacists should ensure that patients
obtain enough supply upon dispensing.

6.2.4.2. Provide effective pain medication therapy

management
6.2.4.2.1. To assess patients’ health status and
medication history.
6.2.4.2.1.1. Pharmacists should ensure that
health management, disease
prevention and healthy lifestyle
behavior are incorporated in the
patients’ assessment and care process.
6.2.4.2.1.2. Pharmacists should conduct thorough
medication history assessment of
prescription medications, non-
prescription medications, herbal
products, and other dietary
supplements consumed by the patient
as well as ensuring medication
reconciliation where appropriate (CP1-
Appendix 8).
6.2.4.2.2. To manage patients’ medication therapy.
6.2.4.2.2.1. Pharmacists should conduct a
systematic process of collecting
patients-specific information, assessing
medication related problems,
developing a prioritized list of
medication related problems and
creating a plan to resolve them (CP2
⦋Manual/IT⦌ - appendix 9).
6.2.4.2.2.2. Pharmacists should assess, identify and
prioritized medication related
problems related to:
6.2.4.2.2.2.1. The clinical appropriateness of each
medication being taken by the
patients, including benefit versus risk
 29

6.2.4.2.2.2.2. The appropriateness of the dose and

dosing regimen of each medication,
including consideration of
indications, contraindications,
potential adverse effects, and
potential problems with concomitant
medications.
6.2.4.2.2.2.3. Therapeutic duplication or other
unnecessary medications.
6.2.4.2.2.2.4. Adherence to the therapy.
6.2.4.2.2.2.5. Untreated diseases or conditions.
6.2.4.2.3. To monitor patients’ progress and outcomes.
6.2.4.2.3.1. Pharmacists should monitor and
evaluate patients’ response to the
therapy, Including its safety and
effectiveness.
6.2.4.2.3.2. Pharmacists should monitor and assess
patients’ adherence to the therapy and
enforce adherence when necessary.
6.2.4.2.3.3. Pharmacists should evaluate patients to
detect symptoms that could be
attributed to adverse events caused by
any of their current medications.
6.2.4.2.3.4. Pharmacists should provide continuity
of care by transferring information on
patients’ medicines as patients move
between sectors of care.
6.2.4.2.3.5. Pharmacists should document and
report any adverse drug reactions or
medication errors detected.
6.2.4.2.4. To provide information about medicines and
other health-related issues.
6.2.4.2.4.1. Pharmacists should provide sufficient
health, disease and medicine-specific
information to patients for their
participation in their decision-making
 30

process regarding a comprehensive

care management plan.
6.2.4.2.4.2. Pharmacists should communicate
appropriate information to the:
6.2.4.2.4.2.1. physicians or other healthcare
professionals, including
6.2.4.2.4.2.2. consultation on the selection of
medications, suggestions to
address identified medication
problems, updates on patients’
progress, and recommended
follow-up care.
6.2.4.2.4.3. Pharmacists should be proactive in
providing education and training on the
appropriate use of medications and
monitoring devices and the importance
of medication adherence to other
healthcare professional.
6.2.4.3. Maintain and professional performance
6.2.4.3.1. To plan and implement continuing
professional development strategies to
improve current and future performance
6.2.4.3.1.1. Pharmacists should undergo the
necessary training for pain
management and take steps to
update their knowledge and skills
in managing acute and chronic pain
(cancer/non-cancer) in adult as
well as paediatric patients
6.2.4.3.1.2 Pharmacists should perceive
continuing education as being
lifelong and be able to demonstrate
evidence of continuing education or
continuing professional
development to improve clinical
knowledge, skills and performance.
6.2.4.3.1.3 Pharmacists should take steps to
 31

update their knowledge and skills

about complementary and
alternative therapies such as
traditional medicines, health
supplements, acupuncture,
homeopathy and naturopathy.
6.2.4.3.1.4 Pharmacists should take steps to
become informed and update
their knowledge on changes to
information on medical products.

6.2.5. PHYSIOTHERAPISTS

6.2.5.1. To be a member of multidisciplinary team.

6.2.5.2. To liaise with other clinical departments
and other healthcare groups (including
T/CM and palliative medicine services) in
order to provide an individualized,
multidisciplinary approach to the
management of pain for every patient who
needs sit.
6.2.5.3. To contribute & facilitate in all activities in
regards of Pain Free Health care facilities
implementation.
6.2.5.4. To promote physiotherapy techniques for
pain management.
6.2.5.5. To perform audit on physiotherapy
management in peri-operative care and pain
management in general ward.
6.2.5.6. To conduct and facilitate clinical research on
physiotherapy and rehabilitation for pain
conditions.
6.2.5.7. To provide pre-operative and antenatal
counseling on the importance of
appropriate physiotherapy techniques to
patient who are referred by the primary
unit.
 32

6.2.6. Occupational Therapist

6.2.6.1. Occupational Therapy uses non-medical
approach to managed pain. The occupational
therapist brings a holistic perspective and
collaborative view of the patient with pain to
the team. Occupational Therapist are
concerned with psychosocial and
environmental factors that contribute to pain
and the impact of pain on occupation of daily
life.
6.2.6.2. To assess activities of daily living (ADLs), work
and school function, leisure pursuits, habits
routines, family and social relationship.
6.2.6.3. To identify the impact of pain in daily life and
degree of impairment, developmental delay or
psychological distress by provides
comprehensive assessment.
6.2.6.4. To performed activities analysis to explore the
impact of pain on occupational developmental
performance (engagement in activities) needs
to be considered from different perspectives,
including factors (biological,
psychological/spiritual,
social/environmental) that contribute to
actual challenges in the individual’s every life.
6.2.6.5. To create preventive strategies to focus on
scheduling and adapting activities.
6.2.6.6. To collaborate between patients and therapist
to ensure the patients’ intervention goal are
identified and recognized by the patient.
6.2.6.7. Occupational Therapist task in acute and
chronic pain management are:
6.2.6.7.1. To give patients and caregiver education
and awareness on pathophysiology of pain
6.2.6.7.2. Uses non-pharmacological technique eg:
 RICE
 33

 Relaxation technique
 Desensitization technique
 Cognitive & Perceptual Training
 Modification of Activities of Daily
Living, Play/Leisure and Work
 Aids and Adaptation

6.2.7. T/CM TEAM

6.2.7.1. To be a member of multidisciplinary team.

6.2.7.2. To follow clinical rounds and case discussion
where relevant
6.2.7.3. To administer appropriate treatment
(acupuncture, massage etc.) when
indicated.
6.2.7.4. To conduct audit on workload and
effectiveness of the service where
applicable.
6.2.7.5. To conduct and facilitate clinical
research in role of T/CM services in pain
management where relevant.
6.2.7.6. To contribute & participate in all
activities in regards of Pain Free Health
care facilities implementation.
 34

7. TRAINING & EDUCATION

7.1. TRAINING OF HEALTH CARE FACILITIES STAFF
7.1.1. At least 60% of health care facilities staff must have
attended the training of Pain as the 5th Vital Sign.
7.1.2. A regular training program must be in place for
health care facilities staff.
7.1.3. Existing staff who have not been trained before
must attend at least one training and all new staff
should be trained within 3 months of joining the
health care facilities.
7.1.4. A refresher course on pain management is
required every 5 years.
7.1.5. Training material should be available in all wards,
clinic areas and other clinical units.
7.1.6. Protocols and guideline on management of pain
should be available for reference in all wards and
clinics.

7.2. PATIENT EDUCATION

7.2.1. Patient education shall start early e.g. In clinics, ED,
during admission to the ward etc.
7.2.2. Pamphlets, posters or other form of information on pain
management shall be available to patients.
7.2.3. Information videos on pain management and pain
free health facilities should be screened at patient
waiting areas.
 35
13
8. IMPLEMENTATION
8.1. SUGGESTED PAIN FREE PROGRAM CERTIFICATION GANTZ CHART
Health Facility Task Year: ……………………………………………………..

Months Within 3
Month 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
before months
Request For Certification
Study The Pain Free Standards
Education & Support from National Pain
Free Hospital (TOT)
Awareness Program for staff (TOT)
Understand, Interpret and Prepare
Implementation Plan
Application and Gap Analysis
Overcome shortfalls
Pre survey Document Submission to
National Committee
Survey for Certification

Received Preliminary report& respond

(if needed)
Received Preliminary report& respond
(if required)
 36

8.2. SUGGESTED IMPLEMENTATION TIMELINE

2nd month 3rd month 4th month 5th month 6th month 7th month 8th month
Implementation Task
Date Date Date Date Date Date Date Date Date Date Date Date Date Date

Training on Pain as 5th Vital Sign

Charting Pain Score and Assessment

Implementing Pain Management

guideline

Multidisciplinary round/discussion

Hospital Committee Meeting

Audit:
Implementation of P5VS –Cross Audit
(inter-department)

Patient’s satisfaction survey

Pain as 5th Vital Sign survey for staff

 37

9. MULTIDISCIPLINARY APPROACH:
9.1. The health care facilities shall organize a schedule for
multidisciplinary pain management ward rounds or a
for multidisciplinary team discussions for selected
cases.

9.2. Attendance records for multidisciplinary ward rounds

or case discussions shall be kept.

9.3. All multidisciplinary case discussions shall be

documented and the records kept according to normal
procedure in the health care facilities (paper or
electronic). The outcome of the discussions will also be
documented and appropriate action recommended
shall be taken.

9.4. The duties and responsibilities of each member of

the Multidisciplinary team shall be as outlined in the
following documents

9.4.1. Primary unit (i.e. the unit the patient is admitted

under – Page 20-22)

9.4.2. Acute Pain Service (APS – page 22-23)

9.4.3. Pharmacist (page 24-28)

9.4.4. Physiotherapist (page 28-29)

9.4.5. T&CM staff (page 29)

14
 38

10. PAIN FREE CERTIFICATION

10.1. PROCESS FLOW CHART (Figure 1)

Health 6-12 month before

Care certification
Facility

3 months before
Request for certification
survey

Implementation of Gantts chart

plan

Pre certification document* submission

(*refer appendix 5)

Feedback given within 1 month

Survey team formation& schedule  Surveyors meet key

staff
 Presentation to
Survey
Surveyors
 Examination of
Report within 3 months documents
 Survey conducted
 Summation
conference

15 Certification
 39
10.2. CERTIFICATION AUTHORITY:
The Pain free certification authority utilizes 2 tier
systems as follows:

10.2.1 National Level

The National Pain Free Steering Committee shall
be appointed by the Deputy Director General of
Health (Medical Program), upon nomination by
the Director of Medical Development Division.
10.2.2 National Technical Working Committee
The National Technical Working Committee is
responsible for the evaluation process for
certification purposes for both private and public
healthcare facilities for matters pertaining to pain
free initiatives which includes:
10.2.2.1. Constituting an evaluation panel to visit and
assess healthcare facilities for the purpose of
pain-free certification;
10.2.2.2. Studying the report of the evaluation panel
10.2.2.3. Submitting the recommendations on
certification for sanction by the Deputy
Director General of Health (Medical Program)
and the Director of Medical Development
Division and acknowledged by DG
10.2.2.4. Reviewing the validity of the evaluation
criteria, standards and procedures from time
to time
10.2.2.5. To submit proposals for changes to Deputy
Director General of Health (Medical Program)
and the Director of Medical Development
Division.
10.2.2.6. To advise the Deputy Director General of
Health (Medical Program) and Director of
Medical Development Division on additional
members for the National Committee.
 40
The National Technical Working Committee is
chaired by a Pain specialist and its members
shall comprise a representative from the
major disciplines from MOH encompassing
anesthetics, surgery, medical, pediatrics, etc.
Each appointment shall be for a period of not
more than three years.
The Secretariat of the National Committee
shall be appointed by the Director of Medical
Development Division from Medical Care
Quality Section (Cawangan Kualiti Penjagaan
Perubatan).
The National Committee shall at all times, to
avoid biasness, abide by the Rules of Natural
Justice which amongst others include:
i. Rules against bias
ii. Rules for the fair hearing
iii. Reasoned decisions

10.2.3. Healthcare facilities Level

The duties and responsibilities of committee are:

10.2.3.1 Training
10.2.3.1.1 Coordinate and conduct Training for Pain
as 5th Vital Sign for nurses and doctors
10.2.3.1.2 Conducting training workshops on non-
pharmacological methods for pain
management (relaxation, massage,
cryotherapy, etc.)
10.2.3.1.3 Patient education activities – information
sheets, public talks and exhibition, Medic
TV

10.2.3.2. Documentation and Promotion

Overseeing the formation of
Multidisciplinary teams to do clinical
rounds (e.g. APS team + surgical team +
 41
physiotherapist + pharmacist do a round
once a month) or multidisciplinary
discussion on selected patients at least 6-8
times per year.

10.2.3.3. Audit and Reporting

10.2.3.3.1. Monitoring of implementation of P5VS in
wards e.g. by nursing audit.
10.2.3.3.2. Monitoring of Day Care Surgery: numbers
and quality (phone call to patient at
home)
10.2.3.3.3. Monitoring of MIS:
 Number of surgeons trained
 Number of procedures performed per
year
 Monitoring the use of non-
pharmacological techniques and T/CM
(where applicable) for pain
management
 Monitoring the use of regional
anaesthesia for post-operative pain
management

10.2.4. Duties and responsibilities of specific unit,

please refer page as mention below;
10.2.4.1. Primary care unit (including Emergency
physician and Public health physician) (page
22-24)
10.2.4.2. Acute Pain Service (page 24-25)
10.2.4.3. Obstetrics & Gynaecology (page 25-26)
10.2.4.4. Pharmacist (page 26-31)
10.2.4.5. Physiotherapist (page 31)
10.2.4.6. Occupational Therapist (page 32)
10.2.4.7. Traditional & Complementary Medicine (page
32-33)
 42
10.3. PFH CERTIFICATION PROCESS:

10.3.1. Process for Certification:

Briefly, the method and procedures of certification
process entails the following steps:

10.3.1.1. Intention for certification:

The Health care facilities intending to go for
PFH certification shall apply to the National
Committee one year in advance in writing.
This will enable the National Committee to
make appropriate plans. (refer appendix 6,
page 74)

10.3.1.2. Training:
Training of health care facilities staff and
patient education, (refer page 34)

10.3.1.3. Submission of pre certification documents:

The healthcare facility need to submit the pre
certification documents to the National PF
Audit Committee via ‘Pain Free Unit, Quality in
Medical Care Section Medical Development
Division Ministry of Health’ NOT LESS THAN 3
months prior to intended and/or scheduled
visit to ensure smooth certification process.
(Refer to appendix 6; page 74).
Documents will be reviewed and feedback
given within 1 month.

10.3.1.4. Selection of Survey Team:

Upon receipt of application, the National
Committee will appoint a Survey Team
consisting of panel members with a balance of
expertise and free of conflict of interest.
 43
10.3.1.5. The Certification Survey Visit:
The Survey Team reviews the facility’s
documentation and visits the facility. During
the visit, the Team validates the facility’s
documentation by interviewing staff, patients
and others associated with service delivery
and management and inspects the physical
resources.
The Team’s chairperson provides an oral exit
report to the facility’s management and staff
that covers the Team’s views about the
strengths and weaknesses of the services
delivery, areas that need attention and
distinctive activities to be encouraged. Input
from the discussion is integrated into the
detailed draft report of the Survey Team’s
findings.

10.3.1.6. The Certification Draft Report:

The Survey Team’s secretary is responsible
for compiling a final draft report from every
member of the team. The draft report is
submitted to Survey team for comments. This
interchange is largely about errors and
omissions rather than about interpretation of
conclusions. The Survey team may consider
comments and appeals from the facility
management and other sources.

10.3.1.7. Decision on Granting Certification:

The Survey Team Chairman or any member of
the Survey Team nominated by the Team
Chairman shall present the final report to the
National Committee.
The National Committee shall evaluate the
Survey Report and other documents from the
facility, if any, before making
recommendations on certification for
ratification by the Deputy Director General of
Health (Medical Program) and the Director of
 44
Medical Development Division

10.3.1.8. Appeal:
Appeal to National Committee and
recommend to Deputy Director General of
Health (Medical Program) and the Director of
Medical Development Division if the facility
fails or conditional certification

10.3.1.9. Audit and monitoring

10.3.1.9.1. The health care facilities shall conduct
appropriate audit at least once a year,
including:
 Implementation of P5VS (Appendix
1&2)
 Patient satisfaction survey
(Appendix 3)
 P5VS staff survey (Appendix 4)
10.3.1.9.2. The audit result shall be available in
Quality Unit of the health care facilities.
10.3.1.9.3. The audit result shall be submitted to Pain
Free Program, Quality Unit in Medical
Care Section Medical Development
Division Ministry of Health every year.
10.3.1.9.4. Quality improvement programs: The
health care facilities are encouraged to
produce additional quality improvement
programs and audits or studies to
measure the effectiveness of the PFH
program.
The process may refer to the process flow
chart (figure 1; page 38, suggested
implementation Gantt chart may refer to
page 35)
 45
10.4. CERTIFICATION:
A facility will be awarded with either any of the
following:
 Conditional.
 Full.
 No Certification.

10.4.1. Full Certification is granted for a maximum

period of THREE YEARS on the basis of
judgment that:
10.4.1.1. There is evidence that the pain free criteria
and activities are being met;
10.4.1.2. There is evidence of quality management
for sustainability of the pain-free program
and the embrace of change.

10.4.2. Conditional may be granted for a maximum

period of ONE YEAR subject to certain
conditions being addressed within specified
periods. The facility is required to submit
periodic reports. The National Committee may
appoint a panel of assessors to revisit the
facility in this category during the period of
certification, depending on the periodic
reports. If the facility does not achieve the
required progress, the certification status may
be reduced to a shorter period of time. It may
also impose additional conditions. Certification
may be granted for shorter periods of time with
conditions if the National Committee identifies
significant deficiencies and non-compliance
with the standards.
Before the period of certification ends, or
sooner if the facility considers that it has
already addressed its deficiencies, the National
Committee conducts a review. The medical
facility may request:
 46
10.4.2.1. Either a full evaluation of the facility and
the course, with a view to granting
certification for a further maximum period;
10.4.2.2. Or a more limited review, concentrating on
the areas where deficiencies were
identified, with a view to extending the
current Certification to the full period.

10.4.3. No Certification: Certification may be refused

where the National Committee considers that
the deficiencies are so serious as to warrant
that action.
The date of certification shall be last day of the
first visit.

10.5. PERIODIC REPORTS:

During the period of certification, the National
Committee requires reports from the facility that may
affect the facility’s ability to implement its pain free
activities, and of the facility’s response to issues raised
in the Certification Report.
Similarly, medical facility with conditional certification
has to report periodically. Reports are formally
considered by the National Committee, which may ask a
facility to clarify or amplify information in a report or
may decide to conduct a special visit to the facility.

10.6. BEST PRACTICE IN CERTIFICATION PROCESS:

At all times the National Committee and the panel of
assessors shall maintain a credible certification process
by adhering to a code of ethics that ensures that
fundamental principles are not compromised by
interest groups in the services, the community, the
profession and government who all have legitimate
interests in the quality and orientation of its services.
 47
10.7. THE CONDUCT OF A CERTIFICATION VISIT:
This guideline sets out the procedures for conducting a
certification visit survey. The procedures are divided
into three parts:
 Procedures prior to the Certification survey.
 Procedures related to the survey.
 Procedures after the survey.

10.7.1. Procedures Prior to the Certification Survey

Visit
The procedures consist of notification of the
Certification visit, preparation of the database by
the facility to be visited and preparation of the
survey team.
10.7.1.1. Notification:
10.7.1.1.1. Facilities to be visited by Survey Teams
will be given at least FOUR MONTHS
notice so that documentation can be
adequately prepared. The notification is
given by National Committee. The facility
will also be notified to prepare the
database.
10.7.1.1.2. Members of the Survey Teams will be
constituted by the National Committee.
The membership of the team should
provide for a balance of expertise, health
service and community interests and
should be free of conflict of interests.
Team members will be given at least TWO
MONTHS notice. The facility to be visited
will be notified of the team members.
10.7.1.1.3. The team should visit the facility well
before the Certification application
lapses.
 48
10.7.1.2. Preparation by facility to be visited
10.7.1.2.1. Facilities to be visited by the Survey
Teams are encouraged to see certification
as top priority.
10.7.1.2.2. The facilities will set up a task force to
prepare the database. The database must
be submitted to the National Committee
two months before the visit. This allows
the team time for detailed study and
clarification of issues before the visit.
10.7.1.2.3. Each facility to be visited by a Survey
Team should appoint a liaison person,
preferably a relatively senior staff, to act
as the key link between the facility and the
Team throughout the site visit. The Health
care facilities Director should notify the
Team’s secretary of the person assigned
to coordinate the visit. The national
committee will issue a letter to the Health
care facilities Director/designee about
plans for the visit.
10.7.1.2.4. The Health care facilities
Director/designee will customize the
tentative schedule for the visit and after
mutual agreement with the survey team,
informs the relevant staff.
10.7.1.2.5. The Health care facilities
Director/designee will provide a
“home/document room” for the survey
team equipped with or with access to a
computer and printer compatible with the
operating system used by the team’s
secretary.
10.7.1.2.6. The facility will also appoint staff to serve
as guides in the visits in the health care
facilities.
10.7.1.2.7. The Health care facilities Director’s office
should assist in making hotel reservation
and ground transportation. Useful
 49
information such as the facility’s bulletin,
a city map, campus guide and instructions
about transportation should be mailed to
the survey team.
10.7.1.3. Tasks and Responsibilities of the Survey
Team
10.7.1.3.1. The database and self-study report will be
given to the survey team at least two
months before the visit. The facility shall
provide survey team with all guideline
related to:
 Criteria and standards.
 Conduct of certification visit.
10.7.1.3.2. The Survey Team will meet on the day
immediately preceding the
commencement of the site visit to:
10.7.1.3.2.1. Allocate specific responsibilities to
scrutinize particular components of
the database and report depending
on members’ expertise and interests.
These responsibilities are then
directly linked to the program of
reviews/interviews conducted
during the visit and to the writing of
the certification report. The team will
have a chairperson who will lead the
team deliberations.
10.7.1.3.2.2. Clarify issues identified from the
database and facility self-study and
concur on what questions to ask and
what further information is required.
10.7.1.3.2.3. Determine which information from
the database that needs to be
validated during the site visit.

10.7.1.3.3. The Chairperson

The Chairperson is expected to lead the
deliberations and the on-site preparation,
 50
to collect the opinions of the team
members and to serve as the team’s
spokesperson during the survey visit.
The Chairperson makes the introductions
with various groups and states briefly the
purpose of the visit. He/she ensures that
the team members pace their works
consolidate their observations and
findings at the end of each day so that the
team’s statements of strength and
concerns as well as facility opportunities
are refined each evening. He/she gives the
final oral report that summaries tentative
findings and conclusions of the team to
the Director of the Health care facilities or
his designee. This oral report should be
given from a written summary finalized
by the team on the last evening of the visit.

10.7.1.3.4. The Team Secretary

10.7.1.3.4.1. A Team Secretary shall appoint
amongst its member.
10.7.1.3.4.2. A Team Secretary will prepare final
survey report and forwarded to
chairperson for approval.

10.7.1.3.5. Team members

Team members assist the chairperson
and secretary in collecting and recording
additional data and impressions during
the visit. They write up sections of the
report assigned to them either during the
survey visit or within one week of the survey
and review the draft prepared by the team
secretary. In reviewing the document the
survey team should pay attention to the
strengths and weaknesses of the facilities.
 51
10.7.1.3.6. The Team Secretariat:
10.7.1.3.6.1. The Survey Team shall be assisted by
a secretariat which is appointed by
the Deputy Director of CKPP.
10.7.1.3.6.2. The Team Secretary shall make all the
arrangements with the health care
facilities, plan the schedule, compile
the data, prepare a tentative
schedule, furnish missing info and
compile the final report. The
secretary should contact the Health
care facilities Director’s office to
supply missing information if
important omissions are detected in
the database by team members.
10.7.1.3.6.3. The Secretariat will not be involved in
the preparation of certification
reports.
10.7.1.3.6.4. The secretariat is responsible to send
or received document from the
facilities.
10.7.1.3.6.5. In reviewing the documents, the
survey team should pay attention to
the strengths and weaknesses of the
facilities

10.7.2. The Survey/Site Visit:

10.7.2.1. The schedule of the visit:
10.7.2.1.1. The Secretariat will give the facility a
tentative schedule which it will
customize. The final schedule should be
mutually accepted by both the facility
and the survey team.
10.7.2.1.2. A reasonable duration shall be mutually
allocated for the visit. An example of a
timetable (appendix 6 & appendix 7) is
given at the end to serve as a guide, with
provision for flexibility of change so that
 52
the team can schedule additional
meetings with key individuals and
groups as required.
10.7.2.1.3. The team meets the senior management
of the health care facility, and the
individuals and committees responsible
for the service delivery.
10.7.2.1.4. The team inspects the physical
resources.
10.7.2.1.5. The first and last hour at survey site will
be set aside for the members of the
Survey Team to meet as a group.
10.7.2.1.6. For guidance, please refer to Appendix
7: Suggested Schedule of Certification
Visit.
10.7.2.2. Decorum and Conduct of Survey team
10.7.2.2.1. The purpose of the certification team is
to:
 Determine if the facility is in
compliance to the standards.
 validate the database and to fill out
missing information and
 Assist facilities to improve standards.
10.7.2.2.2. At the facility, the chairperson explains
the purpose of the visit and the team
introduces themselves.
10.7.2.2.3. The decorum of the team must be very
professional because certification is a
peer review process which is a positive
activity, not punitive. The aim is to be
helpful to the facility and the spirit must
be collegial.
10.7.2.2.4. All interviews are conducted with the
knowledge of the Health care facilities
Director although not usually in his/her
presence. This ensures that dissenting
 53
views can be freely expressed without
being attributed to individuals.
10.7.2.2.5. The team must remember that they are
guests of the facility visited.
10.7.2.2.6. Rules of courtesy include not getting
into arguments and not getting
confrontational.
10.7.2.2.7. The role of the survey team is to evaluate
and they must overcome the temptation
to compare the facility visited with their
own facility. They should not play the
role of consultant. They should
encourage innovation and re-
orientation toward changing health
needs
10.7.2.2.8. The team must validate the database
and look for consistency in the delivery
of pain free initiatives based on criteria
checklist for pain free program
certification.
10.7.2.2.9. All information gained during the visit is
ABSOLUTE CONFIDENTIAL and there
must be no sharing of information
outside of the report. There must be no
other comments apart from the report.
10.7.2.2.10. At the end of each day and at the end of
the visit, the team meets to concur on the
areas of strengths and concerns which
must be validated with the standards
and presented at the exit conference

10.7.2.3. The exit oral report

10.7.2.3.1. An oral report is given to the facility at the
end of the visit by the chairperson of the
team. The presentation gives the facility
immediate feedback, since the
preparation of the detailed report can
require an extended period of time.
 54
10.7.2.3.2. The oral report highlights the unique
areas of strength, emphasizes the areas of
concern which are directly linked to non-
compliance with the standards and
distinctive activities to be encouraged.
10.7.2.3.3. The chairperson asks whether there are
any questions relevant to the report and
gives an opportunity for Director of the
Health care facilities and senior officers to
review and discuss the statement of
findings with the team. Besides correcting
any errors of fact, the discussion should
extend to any draft recommendations and
action that would need a response from
the facility.
10.7.2.3.4. The Survey Chairperson should advise the
health care facility management that the
team’s findings are tentative and will be
reviewed by the National Committees’ for
final report.

10.7.3. Writing The Survey Report

10.7.3.1. The draft report should be organized
according to the document Guide for Writing
a Survey Report (available in electronic
form). The report should give primary
emphasis to description and evaluation of
the pain free program. Appropriate
references should be made to the database,
to document noteworthy strengths and
weaknesses. The survey team’s list of
strengths and concerns should be supported
by documentation in the report narrative,
and the deficiencies should be anchored to
the standards and criteria.
10.7.3.2. The draft of the written report should be
completed by the end of the site visit and
signatures of all team members obtained.
Deadline for team members to submit their
 55
write-ups to the secretary is within seven
days after the visit.
10.7.3.3. The Survey Team’ Secretary is responsible
for completing the final version of the draft
report in two weeks.

10.7.3.4. The report is sent by the Survey Team’

Secretary to the Chairperson. The
Chairperson shall approve it in two weeks
and forward to National Committee.
10.7.3.5. The committee secretariat shall send a copy
of approved report to the surveyed facility.
10.7.3.6. The Health care facilities Director is asked to
correct any errors of fact. If the Director
disagrees with the tone or conclusions of the
report, he or she may send the evidence of
correction to national committee within a
month.
10.7.3.7. The report must be held in confidence and
not released to anyone without
authorization from the National Committee.
10.7.3.8. The survey team report does not necessarily
represent the final report from the National
Committee.
10.7.3.9. The Facility’s certification status will be
made following a consideration of the report
by the National Committee. The secretariat
of the National Committee will notify the
Director of the healthcare facility with copies
to the Deputy Director General of Health
(Medical Program), the Director of Medical
Development Division and the relevant
Pejabat Kesihatan Negeri.
10.7.3.10. The certification status is public information
but the survey findings and deliberations of
the survey team and the National Committee
are confidential.
 56
10.7.3.11. The surveyed facility is at liberty to make
public the survey report and details of the
National Committee decision as it deems
appropriate.

10.8. GUIDELINES FOR WRITING A CERTIFICATION

REPORT:
After the visit, the surveyor team prepares a formal
report. The facility is then given an approved report to
provide evidence of correction and comments. This
interchange is largely about errors and omissions
rather than about the interpretation of conclusions. At
all times the National Committee retains the right to
draw its own conclusions.

10.8.1. Purpose of Survey Report

 To provide a clear picture of the facility’s
environment and objectives, program
organization, resources, and service
deliveries.
 To identify the strengths of the facility.
 To document any concern of the survey team
or opportunities for improvement.
 To note major changes, recently implemented
or underway, especially those that should be
followed-up.

10.8.2. Responsibilities of Team Members in Writing

The Report
Each team member will be given specific tasks and
responsibility for a part of the report. The report
will be discussed and then compiled within seven
days by team secretary.
Portions of the survey report specially assigned to
individual team members should be completed on
site or sent to the team secretary within 7-10 days
of the visit. The team secretary is expected to
complete the draft report shortly after the visit (4
 57
to 6 weeks is optimum). The secretary is
responsible for organizing the contributions from
the other team members, to ensure that the
overall report is coherent, logical, and internally
consistent. If important areas have been omitted
from a team member’s write up, it is the team
secretary’s responsibility either to contact that
member for additional details or to supply the
missing content himself/ herself.
The report should give the team’s narrative
description and comments in the front part of the
report, with references to database sections
collated sequentially in the Appendix at the rear of
the report. This will clearly differentiate survey
commentary from that of the institution.
The team secretary should reserve original copies
of hand-outs, database pages, etc. for
incorporation, as appropriate, in the final report
that is sent to the National Committee for printing.
Please type material on one side of the page only,
and that the type style is conventional.
It is useful for the team secretary to compare the
draft report with the set of strengths and concerns
identified by the survey team, to ensure that all
areas are well documented in the text.
The team chair and secretary should edit the
report for the propriety of attribution to
individual staff concerned. While the commentary
may be important for documentation, specific
persons and departments should, if possible,
remain anonymous.
The final survey report should be sent for review
to:
 Each member of National Committee.
 The Director of Health care facility.

10.8.3. Pain free program Certification Report Format

10.8.3.1. Cover Page
Should include:
 58
Title: e.g. Report of the Pain Free Healthcare
Facility Survey of Healthcare facility …

Date:
Prepared by: The Survey Team appointed by
the National Pain Free
Program Committee of the
Ministry of Health Malaysia.
Footnote: This privileged communication
is the property of the National
Pain Free Program Committee
of the Ministry of Health
Malaysia.
The Survey Team that visited Healthcare
facility … (the name of the health care
facilities) on … (date) is pleased to provide the
following report of its findings and
conclusions.
Respectfully,

Name, Chairperson (signed):

Name, Secretary (signed):

Name, Member:

Name, Member:

Name, Member:

10.8.3.2. Table of Contents

10.8.3.3. Introduction and Composition of the Survey
Team
A typical example:
A survey of Healthcare facility… (name of
health care facilities) was conducted on …
(date) by the Survey Team appointed by the
National Pain Free Program Committee of
MOH. The team expresses its appreciation to
 59
the Health care facilityDirector … (name) and
the administrative staff for their interest and
candor during the survey visit.
The Facility Liaison Officer … (name), and …
(any other persons) deserve special thanks
for the smooth coordination of the visit, tactful
management of scheduling changes and
timely provision of additional items of
information requested during the visit.
After the paragraph introduction, list the
members of the survey team, giving their
names, titles and institutions and their roles in
the survey team as chair, secretary, member
or faculty fellow.

For example:

Chair:
Name:
Designation:

Secretary:
Name:
Designation:

Member:
Name:
Designation:

10.8.3.4. Summary of Survey Team Findings

Summarise the survey team’s findings under
the following headings:
• Strength
• Areas of Concern
• Opportunities for Improvement
 Services/Programs under Development
or Areas in Transition that need to be
followed up.
 60
For each of the above heading, for example,
Institutional Strength, start with Mission and
Objectives, then go on to Services/Program,
Assessment of Service Deliveries, Staff,
Resources, Monitoring and Evaluation,
Governance and Continuous Quality
Improvement. Repeat the same sequence for
Areas of Concern, Opportunities for
Improvement and Program under
Development/ Thrust areas to be followed up.
In general, adhere to the points reported
orally in the exit conferences with the
Healthcare Facility’s Director, and follow the
order in which the items will be listed in the
body of the report. For the concerns or
problems, give a sense of relative urgency and
seriousness, and express any
recommendations in generic or alternative
terms rather than prescriptive solutions. All
items cited here should be supported by
documentation in the body of the report.
10.8.3.5. Partial Certification Survey(S) And Progress
Report(S)
If applicable, summarize (use bullets,
paraphrase and combine items, if necessary,
to be succinct) the key findings and
recommendations of the most recent survey
of the health care facilities, including progress
reports addressing any problems identified
previously. Give the dates of the prior
survey(s) and reports. Conclude this by
summarizing the areas of concern in the
previous survey that have been corrected and
problems that still remain.
10.8.3.6. The Facility Pain Free Database
Comment on the organization, completeness
and internal consistency of the database.
Were the numerical data (applicant,
admissions, financial etc) updated to the
current year?
 61

10.8.3.7. Continuous Quality Improvement

Briefly describe and comment on the
institutional quality system and the
mechanisms for rectifying deficiencies.

10.8.4. Summary
Comment on the health care facility strategic
assessment and planning (or the absence thereof)
that serves as a framework to the accomplishment
of its goals and objectives.
Summaries the evaluation of the pain free
activities, listing the specific strengths,
deficiencies, problem areas and opportunities for
development. This is the most significant portion
of the report and should judge the health care
facilities’ pain free program and activities.

10.8.5. Conclusion
Recommends to the National Committee type of
certification to be granted on the basis of
judgment that:
 The pain free services and activities provided
are relevant and there is evidence that the
objectives are being met.
 There is evidence of quality management for
sustainability of the pain free program and the
embrace of change
If there are significant deficiencies and non-
compliance with the standards evaluated,
conditional or no certification status is granted.
 62

11. RESOURCE MATERIAL

11.1. Teaching and training resource materials
are available in MOH website:
www.moh.gov.my > Penerbitan > Hosptal Bebas
Kesakitan> Bahan Pendidikan
The available material:
11.1.1. P5VS Training Module (Doctors)
11.1.2. P5VS Training Module (Paramedics)
11.1.3. Introduction to Pain Free Health care
facilities
11.1.4. Pain Free Health care facilities:
How to Achieve?
11.1.5. Pain Management - the R-A-T Approach
11.1.6. Multidisciplinary Approach to Pain
Management
11.1.7. Role of Pharmacist in Pain Management
11.1.8. Role of Physiotherapist in pain management
11.1.9. Role of Complementary Medicine in PFH
11.1.10. Achieving Day Care Surgery thru PFH
11.1.11. Minimally Invasive Surgery and PFH

11.2. Available guidelines/ manual are available in

MOH website: www.moh.gov.my --> Penerbitan -->
Hospital Bebas Kesakitan--> Garis panduan
The P5VS Guidelines (2nd edition, 2013) are available
in the attached CD. The books have also been
distributed to all health care facilities with specialists.

11.3. Audit forms

11.3.1. The following Audit forms are available in
the attached CD and also in the Appendices
of this book.
11.3.2. The Audit forms can also be retrieved from
the MOH website: www.moh.gov.my ->
Penerbitan -> Health care facilities Bebas
Kesakitan -> Garispanduan
 63

11.3.3. Borang Audit Pelaksanaan Kesakitan

sebagai tanda vital ke 5:
Appendix 1; paramedic page 64-65
Appendix 2; doctor page 66-67
11.3.4. Borang Soal Selidik Pesakit:
Appendix 3; page 68
11.3.5. Pain as the Fifth Vital Sign: Staff Survey /
Borang soal selidik anggota kerja:
Appendix 4; page 69-70
11.3.6. Laporan Tahunan Pelaksanaan Tahap
Kesakitan Sebagai Tanda Vital Kelima:
Appendix 5; page 71-73
11.3.7. Application form for Pain Free Health care
facilities Survey:
Appendix 6; page 74

11.4. Other materials (in the manual)

Duties and responsibilities of different members of
the Multidisciplinary team are outlined in the
Appendices below:
11.4.1. Primary unit (page 22-24)
11.4.2. Acute Pain Service (page 24-25)
11.4.3. Obstetric Analgesia Team (page 25-26)
11.4.4. Pharmacists (page 26-31)
11.4.5. Physiotherapists (page 31)
11.4.6. Occupational Therapist (page 32)
11.4.7. Traditional and Complementary Medicine
staff (page 32-33)

11.5. Other forms

Other forms that may be useful in the
implementation of PFH are also included in the
Appendices and in the CD attached.
11.5.1. Medication History Assessment Form for
Pharmacy (CP1) page 70
11.5.2. Pharmacotherapy Review (CP2) for IT
Hospital page 77-78, Non-IT page 79-81
11.5.3. Nota rujukan pesakit page 82-83
 64

Appendix 1
Pain 5th Vital Sign Nursing & AMO Audit form
i. Tick (√ ) at the appropriate column; 2. If the item is optional, tick N/A
ii. Add only for Pain score < 4 (0-3) or >4 (4-10) depending on the pain score.

SOURCE OF
S/N ITEM YES NO N/A
INFORMATION
Listen & Observe
S1 Smile and Greet / acknowledge patient
nurse

Explain / inform the purpose of the pain Listen & Observe

S2
assessment ruler. nurse
Listen & Observe
T1 Teach patient to give pain scores.
nurse
Listen & Observe
T2 Re-teach if necessary.
nurse
Add only for Pain score < 4 (0-3)

Pain Score < 4 (0-3)

Observe & check

D1 Document Pain Score
document

T3 Follow the Pain flow chart for nursing action. Observe nurse

T4 Carry out nursing action if necessary. Observe nurse

Ask patient whether she is comfortable and needs Listen & Observe
T5
any medication. nurse

Inform patient to tell the nurse if pain score Listen & Observe
T6
increases. nurse
Observe & check
D2 Document nursing action.
document

Add only for Pain score >4 (4-10)

If pain score is ≥ 4 (4-10),

Observe & check
D1 Document pain score
document

T3 Check Doctor’s prescription ordered. Observe nurse

T4 Check time of last dose analgesics. Observe nurse

 65

Serve medication as prescribed OR

T5 Observe nurse
Carry out nursing action as required.

Inform doctor for prescription if analgesics not Listen & Observe

T6
ordered. nurse
Observe & check
D2 Record pain analgesics after serving.
document

Reassess pain score 30 mins – 1 hour after serving

T7 Observe nurse
of analgesics.

Observe & check

D3 Record reassessed pain score
document
Add for both < 4 (0-3) and >4 (4-10)
Listen / Observe
Advice patient to inform the nurse if pain increase
S3 nurse
(for pain score < 4(0-3) or if pain is not relieved

Listen and respond promptly and politely to Listen & observe

S4
patient’s questions. nurse

Give reassurance if patient requires medication Listen & observe

S5
and medication has not been prescribed. nurse

D3
Accurate and complete documentation. Check document
/D4

AUDIT REPORT (Please [√] in the appropriate box)

RATING
ITEM CONFORMANCE NON CONFORMANCE

Technical Skill

Soft Skill

Documentation

Conformance Non-Conformance
REMARKS
NO. REMARKS

Auditor 1[Name and Signature]: ……………………………

Auditor 2 [Name and Signature]: ……………………………
 66

Appendix 2
BORANG AUDIT PELAKSANAAN PAIN AS THE
FIFTH VITAL SIGN (P5VS) OLEH DOKTOR (30%
daripada jumlah katil yang diwartakan)

SOALAN YA TIDAK

Adakah dokumen rujukan (iaitu garis panduan P5VS) ada

1. di dalam Fail/ Folder Pain Management Kit? (fail/
komputer)

Adakah tahap kesakitan anda (pesakit) diambil oleh

2.
anggota kesihatan? (pesakit)

Adakah anda (pesakit) telah diperkenalkan/ diberi

3.
penerangan tentang tahap kesakitan?
Cth: pembaris skala, tahap kesakitan (pain score) (pesakit)

Adakah tahap kesakitan pesakit diketahui oleh doktor dan

4.
dicatat di dalam fail pesakit? (fail pesakit)
Adakah tahap kesakitan pesakit sentiasa < 4? (fail pesakit)
5. *sekiranya jawapan adalah “YA”, tidak perlu menjawab
soalan 6 & 7.
6.
a) Bagi pesakit yang pre-operative/ bukan operative:
Bagi tahap kesakitan 4 dan ke atas, adakah preskripsi
rawatan kesakitan yang diberi berdasarkan analgesic
ladder? (jika tiada kontraindikasi) (fail pesakit)

b) Bagi pesakit post-operative:

Bagi tahap kesakitan 4 dan ke atas, adakah preskripsi
rawatan kesakitan diberikan kepada pesakit mengikut
analgesic ladder? (jika tiada kontraindikasi) (fail
pesakit)

Bagi tahap kesakitan 4 dan ke atas, adakah penilaian

7.
semula dilakukan dalam masa 1-4 jam selepas menerima
rawatan? (fail pesakit)

JUMLAH (Soalan 1-7)

 67

KESIMPULAN

a) Bagi tahap kesakitan < 4 (Soalan 1-5):

Keberkesanan pelaksanaan P5VS (Berkesan jika jumlah
jawapan ‘Ya’ adalah ≥ 4)

b) Bagi tahap kesakitan ≥ 4 (Soalan 1-7):

Keberkesanan pelaksanaan P5VS (Berkesan jika jumlah
jawapan ‘Ya’ adalah ≥ 6)

SOALAN CATATAN (Remarks)

1
2
3
4
5
6
7

Peratusan Keseluruhan yang dicapai :

(Keberkesanan pelaksanaan ≥ 80%)
………………………………………………………………

Disempurnakan oleh: Disempurnakan oleh:

……………………………. ……………………………..

Auditor 1 Auditor 2
Nama: Nama:
 68

Appendix 3
BORANG SOAL SELIDIK PESAKIT
SOALdibawah.
(Sila jawab semua soalan SELIDIK UNTUK
Kerjasama DIJAWAB
tuan/puan OLEH
amatlah dihargai PESAKIT
untuk menjayakan kajian ini.
Terima kasih.) Objektif kajian ini adalah untuk mendapatkan pendapat anda mengenai penilaian dan
pengurusan kesakitan pesakit bagi tujuan meningkatkan lagi mutu perkhidmatan dan kepuasan pelanggan
di hospital ini.

BIODATA: WAD/ KLINIK: …………………

a. Jantina : Lelaki/ Perempuan

b. Kumpulan Umur : <12 tahun 12-20 tahun

21-30 tahun 31-40 tahun
41-50 tahun 51-60 tahun
61-70 tahun >70 tahun

c. Warganegara : Malaysia/ Bukan Malaysia

d. Tahap Pendidikan : Sekolah Rendah/Sekolah Menengah/

Pengajian Tinggi/ Tiada

BIL SOALAN YA TIDAK

1. Adakah jururawat menilai tahap kesakitan anda :
a. Semasa kemasukan ke wad/ klinik
b. Sepanjang menerima rawatan di wad/ klinik
2. Adakah penerangan yang diberi oleh jururawat tentang
tahap kesakitan dan rawatan kesakitan senang difahami?
3. Adakah rawatan kesakitan diberikan pada jangka masa yang
anda rasa berpatutan?
4. Adakah penilaian tahap kesakitan penting untuk keselesaan
anda?
5. Adakah anda mendapat rawatan kesakitan yang memuaskan semasa dan
selepas :
(tanda yang berkaitan sahaja)
□ Pembedahan
□ Kelahiran anak
□ Prosidur
□ Fisioterapi / Pemulihan carakerja
□ Discaj
6. Adakah anda berpuas hati dengan rawatan kesakitan yang
diterima semasa anda berada di fasiliti kesihatan ini?
 69

Appendix 4
PAIN AS THE FIFTH VITAL SIGN: STAFF SURVEY
A. Gender: Male/ Female
B. Post: HO/MO/Specialist/JM/SN/Sister/Matron/AMO/Allied Health/Pharmacist
C. Department: _____________________

No of years in service: Age (years):

□ <2 years □ 21-30
□ 2-<5 years □ 31-40
□ 5- <10 years □ 41-50
□ >10 years □ >50

D. Have you attended course on P5VS or read the guideline? Yes / No

Instructions: Please tick (√) at the appropriate boxes

Strongly disagree
Strongly agree
Teramat setuju

Teramat tidak
Tidak Setuju
Question
No

Disagree
Soalan

Neutral
Neutral
Agree
Setuju

setuju
Pain assessment should be done on
admission.
1. Penilaian tahap kesakitan perlu dilakukan
semasa kemasukan ke wad/jabatan
kecemasan dan trauma.
In acute pain, opioids prescription has high
risk for addiction.
2. Dalam kesakitan akut, preskripsi opioids
berisiko tinggi untuk menyebabkan
ketagihan.
Pain assessment should ONLY be done
when the patient complains of pain.
3. Penilaian tahap kesakitan HANYA perlu
dilakukan kepada pesakit yang mengadu
sakit.
If pain relief is given to the patient regularly it
will mask all signs of complications or
severity of disease.
4.
Jika ubat analgesik diberi mengikut jadual, ia
akan mengaburi kesemua tanda komplikasi
dan ketenatan penyakit.
 70

Implementing pain as the fifth vital sign

increases current workload, however it
improves patient care.
5. Pelaksanaan penilaian tahap kesakitan
sebagai tanda vital ke-5 menambah beban
kerja, tetapi ia meningkatkan kualiti
penjagaan pesakit.
Implementing pain as the fifth vital sign will
reduce the patient’s length of stay in health
care facilities.
6. Pelaksanaan penilaian tahap kesakitan
sebagai tanda vital ke-5 akan dapat
mengurangkan tempoh pesakit tinggal di
health care facilities.
Implementing pain as the fifth vital sign will
improve patient’s satisfaction with the health
service.
7. Pelaksanaan penilaian tahap kesakitan
sebagai tanda vital ke-5 akan meningkatkan
tahap kepuasan pesakit terhadap
perkhidmatan kesihatan.
Post operative care must involve pain
management.
8.
Penjagaan selepas pembedahan perlu
melibatkan rawatan kesakitan
A patient who keeps asking for morphine
must be addicted to it.
9.
Pesakit yang sering meminta morfin
semestinya ketagih kepada ubat tersebut
Multimodal analgesia has better pain
management
10.
Kombinasi pelbagai ubat analgesik dapat
melegakan kesakitan dengan lebih baik
Multidisciplinary approach is ineffective in
pain management.
11.
Pendekatan pelbagai disiplin tidak efektif
dalam pengurusan kesakitan

Thank you for your cooperation.

Terima kasih atas kerjasama anda
 71

Appendix 5

LAPORAN TAHUNAN PELAKSANAAN TAHAP KESAKITAN

SEBAGAI TANDA VITAL KELIMA (PEKELILING KPK BIL.9/2008)
& HOSPITAL/ KLINIK BEBAS KESAKITAN

SASARAN PENCAPAIAN
BIL AKTIVITI Hospital Hospital Tanpa Klinik
Berpakar Pakar Kesihatan
Pensijilan

Pensijilan

Pensijilan

Pensijilan

Pensijilan
pensijilan
Tanpa

Tanpa

Tanpa
Mesyuarat
Jawatankuasa
Peringkat Hospital /
1.
Pejabat Kesihatan 100% 100% 100%
Daerah secara berkala
2 kali setahun.

Bengkel latihan
Program Bebas
Kesakitan peringkat
2. health care 100% 100% 100%
facilities/Pejabat
Kesihatan Daerah
sekali setahun.

Jabatan klinikal
Hospital/Klinik
Kesihatan mengadakan
3. 100% 100% 100%
CME Program Bebas
Kesakitan 2 kali
setahun.
 72

Jumlah anggota yang

dilatih mengikut
kategori:
a. Pakar Perubatan Bilangan Bilangan Bilangan anggota
anggota yang anggota yang yang dilatih
b. Pegawai Perubatan
dilatih setahun dilatih setahun setahun
c. Pegawai Perubatan
Siswazah Jururawat
(semua kategori)
4.
d. Penolong Pegawai
Perubatan
e. Anggota Kesihatan
Bersekutu
f. Pegawai Farmasi
g. Pembantu
Perawatan
Kesihatan

Jumlah CNE Program

P5VS
A. Hospital
5. (Jabatan/Wad): 12 100% 50% 100%
kali setahun
B. Klinik kesihatan : 2
kali setahun

Jumlah CME Program

P5VS kepada Penolong
6. 100% 100% 100%
Pegawai Perubatan : 4
kali setahun

Jumlah internal audit Bilangan Bilangan Bilangan internal

7. yang dijalankan 2 kali internal audit internal audit audit yang
setahun. yang yang dijalankan
dijalankan dijalankan setahun.
setahun. setahun.
 73

Audit Pelaksanaan Pain Doktor: Doktor:

as the Fifth Vital Sign Melibatkan Melibatkan
dijalankan sekali sekurang- sekurang-
setahun. kurangnya kurangnya
30% daripada 30% daripada
A. Hospital
jumlah katil jumlah katil
Melibatkan
i) Doktor hospital. hospital.
sekurang-
ii) Jururawat (Appendix 2) (Appendix 2)
kurangnya 80%
iii) Penolong Pegawai
8. Jururawat & Jururawat & daripada jumlah
Perubatan
PPP: PPP: anggota
B. Klinik kesihatan Melibatkan Melibatkan kesihatan di
sekurang- sekurang- klinik.
i) Doktor
kurangya 30% kurangya 30%
ii) Jururawat
daripada daripada
iii) Penolong Pegawai
jumlah jumlah
Perubatan
anggota. anggota.
(Appendix 1) (Appendix 1)

Kajian soal selidik Melibatkan Melibatkan Melibatkan

kepuasan pelanggan sekurang- sekurang- sekurang-
(point prevalence) kurangnya kurangnya kurangnya 30%
9.
sekali setahun 30% daripada 30% daripada daripada jumlah
jumlah pesakit jumlah pesakit pesakit di klinik
Rujuk Appendix 3
di hospital. di hospital. kesihatan

Kepuasan pelanggan- Kepuasan Kepuasan Kepuasan

berdasarkan soal pelanggan pelanggan pelanggan ≥80%
10. selidik kepuasan ≥80% ≥80%
pelanggan

Laporan ini berkuat kuasa pada 2018

 74

Appendix 6
APPLICATION FORM FOR PAIN FREE HEALTH CARE FACILITIES SURVEY
Healthcare Facilities Name :
Healthcare Facilities Address :

NUMBER OF DEPARTMENTS

HOSPITAL BEDS

YEAR STARTING PAIN FREE HOSPITAL

PROGRAM

REQUEST DATE FOR SURVEY

Address to: Unit Audit Klinikal, Cawangan Kualiti Penjagaan Perubatan,

Bahagian Perkembangan Perubatan, Aras 4, Blok E1, Kompleks E,
Presint 1, Pusat Pentadbiran Kerajaan Persekutuan, 62590,
Putrajaya
Tel No (office): 03-88831180/ Fax no: 03-88831176
Email: [email protected]
 75

Appendix 7

Suggested Schedule of Certification Visit

TIME AGENDA
0830 – 0900 Arrival of auditors
0900-0930 Opening speech by Hospital Director or
Hospital representative
Briefing by Chief Auditor on audit flow for
the day
0930-1000 Checking of files by audit team
1000-1300 Audit Visit by auditors team (auditors divide
into 2 or 3 teams) to wards, clinics, daycare
and other relevant places around the
hospital.
1300-1400 Lunch
1400-1500 Discussion on auditor’s finding and report
1530-1600 Presentation of auditor’s report
 76

APPENDIX 8
MEDICATION HISTORY ASSESSMENT FORM CP 1
PHARMACY DEPARTMENT,
HOSPITAL…………………………………………………………………….
FORM TO BE FILLED BY THE PHARMACIST UPON PATIENT ADMISSION

Pharmacist Sign & Stamp: _________________________________ Time / Date:

________________________
Original : To be kept in patient’s folder
Duplicate : To be kept by Pharmacy
Pin. 1/10
 77

APPENDIX 9
PHARMACOTHERAPY Pharmacy Department,Hospital ______CP2
REVIEW
DRUG ALLERGY

A. DEMOGRAPHIC DATA
Name : MRN : Age : Gender : M/ F

Race : M / C / I / Others Ht/Wt : DOA : Ward/Bed :

Chief Complaint:

Diagnosis/Impression:

B. MEDICATION
ANTIBIOTIC REGIMEN DATE DATE INDICATION RECONCILIATION
START STOP / REASON NOTE
S-STOP
W-WITHOLD
D-CONTINUE ON
DISCHARGE (+
DURATION)

Date Source M/organism Sensitivity Resistance

Sampling:
Result:

Sampling:
Result:

Sampling
:
Result:
 78

C. DRUG-RELATED ISSUES
• REGIMEN ISSUES
(Drug/Dose/Duration/Frequency/Polypharmacy/Contraindication/Significant
Drug interaction/Incompatibility)
• MISCELLANEOUS (Drug administration error/Suggestion on
investigation/TDM/TPN)

Date Issues Modification/Monitoring Reason Status of

required/Interaction Intervention

D. INFORMATION PROVIDED (ADR/Drug toxicity/Drug dosage/Therapeutic

efficacy/Drug indication/Drug interaction/Pharmacokinetic/TPN/General product
information/Pharmaceutical availability/Pharmaceutical
compatibility/Pharmaceutical identification)

E. PHARMACIST’S NOTES

Pharmacist’s Sign & Stamp:

Reviewed by:
 79

APPENDIX 10
 80

C. MEDICATION
Drug Regime Start Stop Indication/Reason Reconciliation Notes
Date Date for Change S-stopped/W-withold
D-discontinue on discharged
(* Duration)
Antibiotik
Other Medication
 81

D. PHARMACEUTICAL CARE PLAN

Date Pharmaceutical Care Pharmacist’s Outcome

Issues Recommendations /
Plan

Pharmacist’s Sign & Stamp: Reviewed by:

 82

APPENDIX 11 CP4

NOTA RUJUKAN PESAKIT

Jabatan Farmasi, Hospital/ Klinik Kesihatan ______________

Kepada: Pegawai Perubatan/ Pegawai Farmasi/ Penolong Pegawai Perubatan/ Jururawat

Hospital/Klinik ______________________________
PER: PESAKIT: _______________________ _______________ _____________
NAMA MRN NO. K/P
Pesakit ini TELAH/BELUM DIBERI KAUNSELING UBAT-UBATAN untuk dinilai tahap
kefahaman/kepatuhan terhadap terapi ubat yang dipreskripsikan. Diharap pihak tuan/puan
dapat memberi kaunseling dan penilaian susulan yang diperlukan untuk meningkatkan
keberkesanan rawatan.
2. DIAGNOSIS: ____________________________________________
3. SENARAI UBAT TERKINI:

NAMA UBAT/DOS DAN FREKUENSI/JANGKAMASA RAWATAN

4. PENILAIAN KEFAHAMAN & KEPATUHAN TERHADAP TERAPI UBAT (tidak berkenaan jika
pesakit belum dikaunsel)
a. Pesakit telah dikaunsel dan faham tentang ubat/alat bantuan Ya Tidak
pengubatan yang dipreskripsikan:
b.Tahap kepatuhan terhadap ubat-ubatan : Memuaskan Tidak Memuaskan

c. Alat bantuan kepatuhan Pill box Risalah ubat Lain-lain Tiada

5. TINDAKAN SUSULAN YANG DIPERLUKAN (Sila tanda (√) di kotak yang disediakan)

Kaunseling ubat-ubatan dan alat bantuan pengubatan yang dipreskripsikan

Menilai kepatuhan dan kefahaman terhadap terapi ubat yang dipreskripsikan
Pemonitoran terapeutik : (sila nyatakan) ________________________
Isu penyimpanan ubat-ubatan
Lain-lain: (sila nyatakan)
___________________________________________________
 83

Sekian, terima kasih.

Tandatangan dan Cop Pegawai Farmasi

No. Tel. :
Tarikh:

(Salinan asal: untuk dihantar kepada fasiliti yang dirujuk)

(Salinan pendua: untuk simpanan Jabatan Farmasi)