KUALA LUMPUR, August 23 — A national audit found that less than half of beds in three military hospitals were filled from 2018 to 2021 because of a shortage of health care workers, particularly nurses.
According to the Auditor-General’s 2021 Report (Series 1), the general bed occupancy rate (BOR) was under 50 per cent in that period across three audited military hospitals (HAT) operated by the Malaysian Armed Forces (ATM) for military personnel – HAT Tuanku Mizan in Kuala Lumpur (HATTM), HAT Pangkalan TLDM Lumut (96HAT) in Perak, and HAT Kem Terendak (94HAT) in Melaka – including during the pre-pandemic years of 2018 and 2019.
94HAT recorded the lowest BOR at 24.7 per cent in 2019, whereas HAT Tuanku Mizan reported the highest BOR at just 47.3 per cent in 2021.
“No optimum BOR rate was set because the rise and decline of the BOR rate depends on the number of patient admissions to ward,” the Auditor-General’s report quoted the Defence Ministry (Mindef) as saying in a response that the Auditor-General received last May 25.
“Optimum BOR could not be achieved because the ratio of health care workers to patients is too large; the number of postings approved is not in line with the capacity of constructed hospitals; and the need to undergo duties instructed by top management that were given higher priority, like overseas humanitarian missions, and national disaster management and special operations (Covid-19 pandemic).”
On 94HAT in Melaka, Mindef’s June 27 response, as published in the Auditor-General’s report, noted that only 96 of 144 gazetted beds (67 per cent) are currently operational, attributing the decline in operational beds to damage to the medical gas system and to the vacuum system for patients, as well as a shortage of trained nurses for patient care in every shift.
Mindef pointed out that a typical Ministry of Health (MOH) hospital employs 218 trained nurses (grade U29) for a similar number of beds at 150 beds, but 94HAT only has 69 nurses working in both wards and clinics.
“This is a huge and obvious difference, where 94HAT’s operations would certainly be disrupted and prevent the improvement of patient care in the ward.”
Positions for trained nurses are based on the Federal Establishment Document (Military) [FED (M)] approved by the service.
On HATTM in the capital city, Mindef told the Auditor-General last June 27 that only 206 of 282 gazetted beds are currently operational, or 73 per cent, due to the lack of trained nurses to care for patients in each shift.
Just 80 per cent of vacancies for trained civilian and military nurses in the Kuala Lumpur military hospital are filled.
“The number of operational gazetted beds depends on the current staffing strength,” said Mindef in the Auditor-General’s report.
The ratio of nurse to patients according to MOH’s level of care is as follows:
- (1:1): Patients with ventilator/ patient in the maternity ward
- (1:2) Post extubation, patient with trachy, high flow mask, bedridden and close monitoring
- (1:4) Patients who can self-manage and are on intravenous drip, drainage, and so on
- (1:6) Patients who can self-manage, walk, or are discharged
As the HATTM does not have adequate staff, the facility is unable to follow MOH’s standard of care, said Mindef.
With the current ward operations consisting of 206 beds spanning 10 wards, and two high dependency wards (HDW) – one ICU ward and one NICU ward – Mindef noted that the ratio of nurses to patients is insufficient at HATTM.
Mindef cited as an example that the facility needs at least four nurses per shift (based on the 1:6 ratio) to operate the main ward with a capacity of 20 beds.
“HATTM will make a review to ensure that current positions are in line with the current increase in patient admissions to wards compared to previous years,” said Mindef.
96HAT’s Specialist And Orthopaedic Clinics Miss Consultation, Appointment Targets
The Auditor-General’s report found that from 2018 to 2020, both specialist and orthopaedic clinics at 96HAT failed to meet the target of 80 per cent of patients receiving treatment services within 90 minutes from registration to seeing the specialist doctor.
The Perak military hospital only achieved 58 per cent to 73 per cent in that period.
Two reasons given for the clinics’ inability to meet the objective: first, routine ward rounds that specialists need to complete before beginning their duties at the clinic, and second, ward calls coming in during the clinic’s operational hours that pull specialists out of the clinics and into the wards.
Another objective that specialist and orthopaedic clinics were unable to meet was giving 80 per cent of new patients appointments within a month. 96HAT’s rates of achievement ranged between 43 per cent and 77.6 per cent from the years 2018 to 2021.
The reasons given for the inability to meet this goal were the prioritisation of repeat patients and emergency cases, as well as the manual process of recording patients’ appointment dates that complicates reviewing empty slots for appointments.
96HAT’s Anaesthetic Unit Misses Anaesthesisation Targets
The goal for the Anaesthetic Unit at 96HAT is to anaesthesise 90 per cent of elective cases by 8.30am.
According to the Auditor-General’s report, the unit was unable to meet this goal as the surgeons were often the same specialist doctors at the specialist department or clinic who conducted ward rounds in the morning before going to the operation theatre.
As a result, achievement rates stood between 58.7 per cent and 76.4 per cent from the years 2018 to 2021.
HATTM’s Anaesthetic Department Exceeded 5% Case Cancellations In 2019, 2021
As for the Anaesthetic Department at Kuala Lumpur’s HATTM, it was able to meet its goal for the years 2018 and 2020, as case cancellations only amounted to 5 per cent and 3.8 per cent respectively.
However, in 2019 and 2021, the target of under 5 per cent case cancellation was not met as elective case cancellation – due to patients’ medication problems — stood at 5.4 per cent and 6.6 per cent respectively.
HATTM’s Military Medical Department Misses Report Targets
The Auditor-General’s report found that HATTM’s Military Medical Department failed to achieve its target of completing 70 per cent of reports by the ATM Senior Medical Officers Board within a month from examination.
The department only achieved between 67.4 per cent and 64.8 per cent between 2018 and 2021, mainly due to the daily workload of medical officers, where only one specialist is available to conduct annual health examinations for up to 45 people every day, comprising 25 to 30 members and 12 to 15 senior officials.
For 2021, medical officers were involved in unexpected outside duties, like treating Covid-19 patients and the department’s Covid-19 vaccination programme.
Only 94HAT Achieves All Objectives
The Auditor-General found that 94HAT was the only military hospital out of three audited from 2018 to 2021 that achieved all six Quality Objectives set, whereas HATTM achieved six of eight and 96HAT achieved three of six.
HATTM serves the highest number of patients at 95,281, followed by 96HAT (58,658) and 94HAT (42,100). In total, the three military hospitals in Kuala Lumpur, Perak, and Melaka serve 196,039 patients.
These patients comprise 92,389 military personnel, 59,708 veterans, 24,222 members of the general public, and 19,720 family members of staff in the ATM.
ATM runs five military hospitals. Besides the three that were audited for this report, the other two military hospitals are HAT Wilayah Kota Kinabalu in Sabah and HTD Kem Syed Sirajuddin in Negeri Sembilan.
“HAT have successfully provided satisfactory health care services for all ATM members and dependents,” said the Auditor-General.
The Auditor-General recommended that military hospitals, ATM’s health service division, and Mindef review Quality Objectives set for each military hospital, especially in terms of setting targeted times in beginning service by taking into account the medical team’s workload.
The national audit also recommended reviewing needed vacancies and to consider using a hospital information system, especially for recording patients’ details to replace the manual recording method in the appointment book.