HOSPITAL POLICY 2014

CLINICAL SERVICES
OPHTHALMOLOGYDEPARTMENTAL POLICY
HOSPITAL TENGKU AMPUAN AFZAN,KUANTAN

OPHTHALMOLOGY DEPARTMENTAL POLICY

INTRODUCTION

The Department of Ophthalmology, Hospital Tengku Ampuan Afzan serves as the regional
referral centre for Ophthalmology Services. Its core business includes:

1.1. Provision of tertiary eye care services

1.2. Provision of secondary eye care services
1.3. Provision of emergency eye care services
1.4. Provision of Optometry and Visual Rehabilitation Services
1.5. Training of personnel involved in eye care delivery
1.6. Prevention of Blindness

In line with the vision of the Ministry of Health it will provide a patient focussed holistic
approach in the management of patients with eye problems.

2. VISION

Excellence in the provision of eye care services

3. MISSION

We are committed to:

3.1. The provision of quality ophthalmic services.
3.2. The ongoing training of all staff, who will in turn contribute to the realisation of our
vision.
3.3. The promotion of ocular health, the prevention of avoidable blindness and visual
rehabilitation with emphasis on the participation of each individual in his/her own care.

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3.4. The quest for better understanding of local disease patterns to enable healthcare-related
strategies to be more effectively planned and evaluated.

4. OBJECTIVES

4.1. To provide excellent clinical services in a patient-friendly setting, continuously striving

to optimise patient comfort.
4.2. To play an active role in continuous professional development of eye care personnel
through in house continuing medical education programs.
4.3. To assume a leadership role in setting clinical practice standards.
4.4. To participate in clinic and health system research by engaging an ongoing clinical data
collection.

QUALITY ASSURANCE

The department is committed on nurturing a quality culture among the staff, and establishing a
quality system that consistently provides a high standard of ophthalmic care to the community.

Objectives
To ensure that referrals to the department are timely managed (aspect of timeliness)
4.5. To ensure that appropriate level of care is given to patients based on the complexity of
their condition and individual needs. (aspect of appropriateness of care)
4.6. To develop, and continuously improve on, efficient work processes in all aspects of our
core businesses.
4.7. To achieve good clinical outcomes
4.8. To achieve patient satisfaction
4.9. To eliminate wasteful habits and practices

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VALUES

4.10. Quality – We shall base our patient management on current best scientific
evidence, and strive to consistently apply these knowledge and principles in a
manner that is appropriate to our local situation.
4.11. Professionalism – Our conduct in relation to our patients, as well as the rest of the
general and medical community shall be ethical, socially responsible and
characterised by mutual cooperation and respect.
4.12. Teamwork – We shall endeavour to nurture a working environment which
promotes joy and pride in work, so that each individual may be inspired to
combine his/her talents and best efforts towards the realisation of our mission.
4.13. Caring Service – We subscribe to the concept of a holistic approach in health care,
which transcends the mere provision of medical facilities. We affirm the
importance of empathy, warmth, and the human touch in contributing to the
patient’s total well being.
4.14. Process Excellence - We recognise that excellent work processes are a
prerequisite for, though not an equivalent to, a quality system. We shall continue
to aim for process excellence, always remaining open to continuous change for
improvement.

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5. ORGANISATION
The department delivers its services through the provision of service systems to ensure quality
service delivery. The manning of each service system is by a trained senior member of the team
who is in turn accountable to the head of department. He or she is responsible for the planning,
organisation supervision, record keeping, evaluation, training and provision of leadership role.

5.1. Service Systems

5.1.1. Outpatient Services
5.1.1.1. Emergency Eye Care Services
5.1.1.2. General Ophthalmology Services
5.1.1.3. Diabetic Eye Care Services

5.1.1.4. Subspecialty Services:

5.1.1.4.1. Vitreoretinal Surgery
5.1.1.4.2. Glaucoma
5.1.1.4.3. Oculoplastics and Orbital Surgery
5.1.1.4.4. Optometry and Visual Rehabilitation Services

5.1.2. Inpatient Services

5.1.3. Ambulatory Care Services
5.1.4. Training Services – conduct of:
5.1.4.1. Open System postgraduate Ophthalmology Training Programme
5.1.4.2. Ophthalmology Subspecialty Training Programme
5.1.5. Preventive Ophthalmology Services
5.1.5.1. Eye health promotion
5.1.5.2. Screening for Retinopathy of Prematurity
5.1.5.3. Screening for Diabetic Retinopathy
5.1.5.4. Training of primary health care providers

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5.2. Operation Hours

5.2.1. Emergency Eye Care Services – 24 hours
5.2.2. Inpatient services – 24 hours
5.2.3. Outpatient Services – 8 a.m. to 5 p.m.
5.2.4. Ambulatory Care Service – 8 a.m. to 5 p.m.

6. FACILITIES
6.1. Outpatient
6.1.1. General
The Ophthalmology outpatient clinic is situated on Level 2 of the Ambulatory Care
Complex. The reception and waiting areas are well lit and there is adequate space to
allow free movement of patients. Facilities for health education and promotion are
provided in the waiting area. A Digital Calling System is in place to ensure smooth
running of the clinic
There is also easy access to the outpatient Pharmacy, which is located at the ground floor
of the same complex. Access to the Radiology Department, which is situated also at the
ground floor, is via lifts located adjacent to the eye clinic.

6.1.2. Vision Room

One room within a 3 metre long room, situated in front of the main waiting area is
designated for the assessment of vision by a paramedical staff of patients attending the
eye clinic prior to being seen by the attending doctor. Where indicated intraocular
pressure measurements using a Tonopen and dilatation of pupils are pupils are also
carried out. The cubicles are equipped with a Snellen Chart, a mirror, pointer and an
occluder with attached pinhole each.

6.2. Professionalism – Our conduct in relation to our patients, as well as the rest of the
general and medical community shall be ethical, socially responsible and
characterised by mutual cooperation and respect.

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HOSPITAL TENGKU AMPUAN AFZAN,KUANTAN
6.3. Teamwork – We shall endeavour to nurture a working
environment which promotes joy and pride in work, so that each individual may
be inspired to combine his/her talents and best efforts towards the realisation of
our mission.
6.4. Caring Service – We subscribe to the concept of a holistic approach in health care,
which transcends the mere provision of medical facilities. We affirm the
importance of empathy, warmth, and the human touch in contributing to the
patient’s total well being.
6.5. Process Excellence - We recognise that excellent work processes are a prerequisite for,
though not an equivalent to, a quality system. We shall continue to aim for
process excellence, always remaining open to continuous change for
improvement.

7. ORGANISATION
The department delivers its services through the provision of service systems to ensure quality
service delivery. The manning of each service system is by a trained senior member of the team
who is in turn accountable to the head of department. He or she is responsible for the planning,
organisation supervision, record keeping, evaluation, training and provision of leadership role.

7.1. Service Systems

7.1.1. Outpatient Services
7.1.1.1. Emergency Eye Care Services
7.1.1.2. General Ophthalmology Services
7.1.1.3. Diabetic Eye Care Services
7.1.1.4. Subspecialty Services:
7.1.1.4.1. Vitreoretinal Surgery
7.1.1.4.2. Glaucoma
7.1.1.4.3. Oculoplastics and Orbital Surgery
7.1.1.4.4. Optometry and Visual Rehabilitation Services

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7.1.2. Inpatient Services

7.1.3. Ambulatory Care Services
7.1.4. Training Services – conduct of:
7.1.4.1. Open System postgraduate Ophthalmology Training Programme
7.1.4.2. Ophthalmology Subspecialty Training Programme
7.1.5. Preventive Ophthalmology Services
7.1.5.1. Eye health promotion
7.1.5.2. Screening for Retinopathy of Prematurity
7.1.5.3. Screening for Diabetic Retinopathy
7.1.5.4. Training of primary health care providers

7.2. Operation Hours

7.2.1. Emergency Eye Care Services – 24 hours
7.2.2. Inpatient services – 24 hours
7.2.3. Outpatient Services – 8 a.m. to 5 p.m.
7.2.4. Ambulatory Care Service – 8 a.m. to 5 p.m.

8. FACILITIES
8.1. Outpatient
8.1.1. General
The Ophthalmology outpatient clinic is situated on Level 2 of the Ambulatory Care
Complex. The reception and waiting areas are well lit and there is adequate space to
allow free movement of patients. Facilities for health education and promotion are
provided in the waiting area. A Digital Calling System is in place to ensure smooth
running of the clinic
There is also easy access to the outpatient Pharmacy, which is located at the ground floor
of the same complex. Access to the Radiology Department, which is situated also at the
ground floor, is via lifts located adjacent to the eye clinic.

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8.1.2. Vision Room

One room within a 3 metre long room, situated in front of the main waiting area is
designated for the assessment of vision by a paramedical staff of patients attending the
eye clinic prior to being seen by the attending doctor. Where indicated intraocular
pressure measurements using a Tonopen and dilatation of pupils are pupils are also
carried out. The cubicles are equipped with a Snellen Chart, a mirror, pointer and an
occluder with attached pinhole each.

9. STAFFING LEVELS
The department is manned by a team comprising of the following personnel:
9.1. Ophthalmologists with Subspecialty Training in the following areas:
9.1.1. Vitreoretinal Surgery
9.1.2. Oculoplastics and Orbital Surgery
9.1.3. Glaucoma
9.2. Trainees in Subspecialty Training Programme (by rotation)
9.3. General Ophthalmologists
9.4. Trainees in local Postgraduate Training Programme (by rotation)
9.5. Service medical officers
9.6. Optometrists – 6 in number
9.7. Paramedical Staff
9.7.1. Clinic – 15 in number of whom 5 completed training in Post basic Ophthalmic
Nursing.
9.7.2. Ward – 15 in number, including the ward Sister, of whom 6 completed training in
Post basic Ophthalmic Nursing.

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10. DEPARTMENTAL OPERATIONAL POLICY

10.1. General
10.1.1. Patients referred to the Ophthalmology Department shall be given timely
management. A triaging system shall be put in place to facilitate this.
10.1.2. Patients referred to the Ophthalmology Department shall be attended to by trained
personnel
10.1.3. Ongoing training shall be an integral part of the services provided by the
Ophthalmology Department
10.1.4. The department shall engage in activities to promote ocular health and prevent
blindness at all levels of care
10.1.5. Active surveillance and monitoring of services provided shall play an important
role in continuous quality improvement.

10.2. Specific
10.2.1. Emergency Eye Care services
10.2.1.1. Dedicated emergency eye care services shall be made available daily in the
outpatient clinic during operational hours
10.2.1.2. The services at the emergency eye clinic shall be under the supervision of
a Specialist.
10.2.1.3. Triaging shall be made available to ensure timeliness and appropriateness
of care
10.2.1.4. After operational hours all referrals shall be attended to within 1 hour by
the doctor on call.
10.2.1.5. The team on call shall comprise of a paramedical staff, medical officer,
specialist and a subspecialist to provide access to specific care when
required.

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10.2.2. General Ophthalmology services

10.2.2.1. General Ophthalmology Outpatient Clinics shall be conducted under the
supervision of a Specialist.
10.2.2.2. Patients attending the Ophthalmology Outpatient clinics shall have their
visual acuity assessed, unless it is otherwise indicated.
10.2.2.3. All new patients above the age of 40 years and those with a family history
of glaucoma shall have their intraocular pressure assessed, unless it is
otherwise indicated.
10.2.2.4. The family members of patients with ocular conditions that are hereditary
and familial in origin shall have their eyes examined.
10.2.2.5. All efforts shall be made to discharge patients who cease to require
specialized care.
10.2.2.6. A full ocular examination shall be performed at least once before a patient
is discharged.
10.2.3. Diabetic Eye Care services
10.2.3.1. A dedicated Diabetic Eye Clinic shall be conducted at least once a week.
10.2.3.2. The services provided shall be under the supervision of a Specialist.
10.2.3.3. All new patients referred to the Ophthalmology Department shall be seen
within 6 weeks. A screening program using fundus photography manned
by a trained paramedical staff shall be established to facilitate this.
10.2.3.4. The policy on the assessment for visual acuity and intraocular pressure in
the General Ophthalmology Clinic shall apply.
10.2.4. Subspecialty services
10.2.4.1. All subspecialty clinics shall be conducted under the supervision of a
subspecialist in the area concerned
10.2.4.2. All new cases referred shall be reviewed by a specialist trained in the
specific area of subspecialty
10.2.4.3. All surgeries and especially Vitreoretinal surgery shall be performed
within a reasonable time to prevent loss of vision

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10.2.4.4. All surgeries shall be conducted under the supervision of a specialist

trained in the specific area of subspecialty
10.2.4.5. All patients undergoing surgery shall be given be given instructions on
preoperative and post operative care specific to the area of subspecialty to
enhance outcome
10.2.4.6. All patients with low vision shall be referred to the Low Vision Clinic to
maximise their visual potential.
10.2.5. Preoperative and Postoperative Care services
10.2.5.1. Preoperative assessment and counseling shall be conducted for patients
undergoing surgery.
10.2.5.2. All patients undergoing surgery shall be given the necessary information
(written or verbal) prior to or at the consent for surgery.
10.2.5.3. The policy related to the procurement of intraocular lens shall be adhered
to.
10.2.5.4. Post intraocularsurgery patients shall be reviewed at least once within a
week of surgery.
10.2.6. Optometry Services
10.2.6.1. Optometry services shall be provided to complement services provided by
the doctors
10.2.6.2. Low Vision and Contact Lens services shall be provided as part of
Optometry services
10.2.6.3. Optometry clinics shall be conducted under the supervision of a senior
Optometrist appointed by the head of department
10.2.6.4. All Optometrists shall be trained to perform investigative and screening
procedures as part of their extended role

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10.2.7. Inpatient services

10.2.7.1. All patients admitted to the Eye Ward shall be attended to by the Medical
Officer within 1 hour
10.2.7.2. All patients admitted shall be reviewed by a Specialist at least once during
hospitalization except in cases discharged within 24 hours.
10.2.7.3. Counseling in eye care shall be provided to all patients

10.2.8. Inpatient Ophthalmic Surgery services

10.2.8.1. All Operating Theatre policies shall be adhered to.
10.2.8.2. All patients undergoing surgery shall have the side of operation marked
before transfer to the operating room
10.2.8.3. The members of the operating team shall take a pause prior to surgery
(time out) to identify the correct patient, correct site, correct procedure and
correct materials to be used.
10.2.8.4. Any member of the team shall be empowered to stop the process of
preparing the patient for surgery if an inconsistency or error is discovered.
(Hard stop process)
10.2.8.5. Post operative infection occurring in a cluster of 2 cases or more within 2
weeks shall warrant investigation by the Infection Control Unit
10.2.8.6. An incident report shall be made for the following events:
10.2.8.6.1. Unplanned return to operation theatre within 1 week
10.2.8.6.2. Postoperative Infectious Endophthalmitis
10.2.8.6.3. Procedures performed on the wrong patient or the wrong side
10.2.8.6.4. Unexpected peri-operative death or patient collapse requiring
resuscitation during eye surgery
10.2.8.6.5. Perforation of globe from periocular injections
10.2.8.6.6. Expulsive haemorrhage
10.2.8.6.7. Wrong IOL implantation
10.2.8.6.8. IOL opacification in vivo or post operatively and faulty IOL.

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10.2.8.6.9. Medication related adverse events – eg. Toxic anterior segment

syndrome following intra-cameral injection
10.2.8.6.10. Surgical device failure
10.2.8.7. All patients undergoing surgery under local anaesthesia shall have their
vital signs monitored throughout surgery.

10.2.9. Day Care services

10.2.9.1. All Ambulatory Care Centre policies shall be adhered to
10.2.9.2. All Operation Theatre Policies regarding inpatient Ophthalmic surgery as
stated above shall be adhered to
10.2.9.3. Observation post procedure shall be stable for at least 1 hour prior to
discharge.

10.3. Policy on the procurement of intraocular lens

10.3.1. General Rule - All procurement of IOL shall be done through a third party
10.3.2. Responsibilities of the supplier
10.3.2.1. The supplier shall furnish the department with the range of IOLs and
viscoelastic device available in the market and the price list.
10.3.2.2. All suppliers to the individual hospital/department are required to submit a
copy of the price list to the Ophthalmology Head of Service.
10.3.2.3. The supplier shall be responsible to ensure an uninterrupted supply of IOL
and viscoelastic device
10.3.2.4. The supplier shall ensure timely delivery of the package for the surgery
10.3.2.5. The supplier shall ensure that a back up anterior chamber IOL (AC IOL)
is made available for exchange should the need arise
10.3.2.6. The supplier shall ensure that a receipt is given to the patient

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10.3.3. Responsibilities of Ophthalmology Department Staff

10.3.3.1. The price list provided by the supplier shall be made available to the staff
and patient at the time of pre-operative assessment and counseling
10.3.3.2. The doctor in charge shall provide advice on the choice of lenses and
viscoelastic device and write the appropriate prescription
10.3.3.3. The patient shall present the prescription to the supplier and all dealings
henceforth shall be direct with the supplier
10.3.3.4. No staff in the department shall be involved in the collection of payments
on behalf of the supplier
10.3.3.5. An avenue for complaints at departmental and hospital level shall be made
available
10.4. Policy on Training
10.4.1. All staff in the Ophthalmology Department involved in patient care shall be
appropriately trained in their specific areas of work.
10.4.2. All attempts shall be made to create opportunities for staff to attend courses for a
period not less than 7 days in a year.
10.4.3. A training Committee shall be made available to organize in house training
programmes and oversee specific training programmes in accredited centres.
10.4.4. Quarterly interview shall be conducted for the monitoring of candidates progress
in the postgraduate and subspecialty training programmes.
10.4.5. Training of primary healthcare workers (doctors and paramedical staff) shall be
conducted at least once a year for each category at the state level

10.5. Policy on the Management of Medical Reports

10.5.1. A departmental coordinator shall be appointed to manage requests for medical
reports from the department
10.5.2. All medical reports written by medical reports shall be reviewed by the Specialist
in charge of the case before despatch to the Medical Records Department

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10.5.3. All requests for medical reports shall be completed
within 2 weeks and immediately despatched.
10.5.4. Allocation of responsibility to write the medical reports shall be based on the
complexity and the doctor must have been involved in the management of the
patient.
10.5.4.1. Medical Officers shall write reports that are simple and straightforward
only
10.5.4.2. Specialists shall write reports on patients that are being treated for
problems in the relevant subspecialties especially those with medico legal
implications
10.5.4.3. Specialists shall reply to any subsequent queries or clarifications (by the
requesting party) on the medical report written by him/herself or by a
medical officer in the team
10.5.4.4. In the case of any doubt the HOD shall be consulted
10.5.5. The department coordinator shall send a soft copy of the requests and names of
doctors assigned to HOD for monitoring
10.5.6. HOD to be notified of all medical report requests where a legal action is being or
already initiated

11. HOSPITAL WIDE POLICY

All relevant hospital wide policies shall be adhered to.

12. KEY PERFORMANCE INDICATORS

Key performance indicators as recommended by the Quality Unit of the Ministry of Health for
Ophthalmology Services shall apply and are as appended.

13. Outreach program

The department is committed to do at least 3 outreach program within a period of 1 year. This
may included events such as World Glaucoma Day, World Sight Day any events outside the
Hospital organised by NGOs.

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14. DELIVERING AND MONITORING STANDARDS

14.1. Audit – shall be conducted on identified cases every month
14.2. Incident Reporting – Significant incidents in addition to that mentioned
above shall be reported, analysed and monitored.
14.3. Complaints Monitoring – all complaints shall be recorded and review at
departmental management meeting.

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KEY PERFORMANCE INDICATORS FOR OPHTHALMOLOGY SERVICES

Optimal Target /
Standard

Percentage of diabetic mellitus patients that were

given appointment for first consultation within (≤)
6 weeks at Ophthalmology Clinic >80%

Percentage of patients developed infectious

endophthalmitis following cataract surgery (2 < 0.2%
cases per 1000 operations)

Percentage of patients without ocular co-

morbidity obtained visual acuity of 6/12 or better
within (≤) 3 months following cataract surgery >85%

Percentage of patient with unplanned readmission

within 24hours of discharge <2%

Percentage of targeted ophthalmology services that

provided by ophthalmologist to the designated >75%
hospital ( Outreach Program )

Percentage of unplanned return to operating

theatre within (≤) one week after cataract surgery <5%

Percentage of button hole of conjunctiva in <5%

primary trabeculectomy

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OPHTHALMOLOGY CLINIC SCHEDULE

CLINIC TYPE MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

General √ √ √ √ √
Ophthalmology
Active Clinic √ √ √ √ √
(Emergency)
Diabetic Clinic √ √ √ √
(Screening)
Preoperative √ √ √ √ √
Clinic
Post operative √ √ √ √ √
Clinic
Vitreoretinal √
(VR) Surgery
Clinic
Glaucoma Clinic √

Oculoplastics √
Clinic
ROP clinic √

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OPHTHALMOLOGY PROCEDURES SCHEDULE

PROCEDURE MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

Optometry -
Refraction √ √ √ √ √

Optometry –
Orthoptic √ √ √ √ √
Binocular Vision
Optometry -Low √
Vision

Optometry – √
Contact Lens

Visual Field √ √ √ √ √

Optic Nerve √ √ √ √ √
Head
Assessment
(OCT)
Laser Procedures √ √ √ √

Fundus √
Fluorescein
Angiography

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OPHTHALMOLOGY OPERATING THEATRE SCHEDULE

OPERATION MONDAY TUESDAY WEDNESDAY THURSDAY

THEATRE

General Operating Cataract Surgery Glaucoma Oculoplastic VR Surgery

Theatre (GOT) & Minor
Procedures

Day Care Operating Cataract Surgery Cataract Surgery & Cataract Surgery Cataract Surgery &
Theatre (ACC OT) & Minor Minor Procedures & Minor Minor Procedures
Procedures Procedures

General Anaesthetics Service in GOT

Tuesday : 8 a.m. to 5 p.m.

Wednesday : 8 a.m. to 5 p.m.

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OPHTHALMOLOGY DEPARTMENT MANAGEMENT COMMITTEE

Committee Members

1. Head of Department - Chairperson

2. Specialist
3. Senior Medical Officer
4. Optometrist in Charge
5. Sister in charge of Ward
6. Assistant Medical Officer/Sister in charge of Clinic
7. PPK in charge
8. Representative from Operation Theatre and/or Ambulatory Care centre
9. Any other representative as and when necessary

TERMS OF REFERENCE

1. To plan and administer services provided by the department

2. To define operational policies and standard operating procedures
3. To plan for equipment procurement and maintenance
4. To plan manpower requirements
5. To monitor service outcomes
6. To ensure that continuous quality improvement activities are carried out

Frequency of meeting – every week or at least once in a month

CLINICAL SERVICES OPHTHALMOLOGY DEPARTMENTAL POLICY

HOSPITAL POLICY 2014
CLINICAL SERVICES
OPHTHALMOLOGYDEPARTMENTAL POLICY
HOSPITAL TENGKU AMPUAN AFZAN,KUANTAN

OPHTHALMOLOGY DEPARTMENT TRAINING COMMITTEE

Committee Members

1. Head of Department/Appointed Specialist - Chairperson

2. Specialist
3. Medical Officer Representative
4. Optometrist
5. Medical Assistant/Sister in charge of Clinic or Ward

TERMS OF REFERENCE

1. To plan and administer training programmes conducted by the department

2. To determine the requirements and conduct in house training for all category of staff
3. To maintain a training database
4. To monitor performance of trainees and take corrective measures
5. To ensure credentialing and privileging processes are in place
6. To monitor and coordinate research activities in the department.

Frequency of meeting – 2 to 3 per year

CLINICAL SERVICES OPHTHALMOLOGY DEPARTMENTAL POLICY