Governance by Design for University Teaching Hospitals: A Reform Ready National Governance Architecture for Malaysia’s Health System

This protocol presents a system-wide, pathway centred governance architecture designed for university teaching hospitals in Malaysia. It establishes structured decision rights, validated KPIs, real time dashboards, incident learning SLAs, resource stewardship mechanisms, and FHIR consistent interoperability. The architecture aligns with Malaysia’s Health White Paper (2023), WHO Global Patient Safety Action Plan (2021–2030), WHO Country Cooperation Strategy Malaysia (2024–2028), and the OECD Health System Performance Assessment Framework (2024). The protocol includes a 0–36 month implementation roadmap with decision gates, an external validation strategy (ITS, stepped wedge pilots, fidelity audits), and a full annex set of governance artifacts. It is designed for phased expansion to public MOH hospitals after successful implementation in teaching hospitals. Supporting evidence base and ethics approval (Protocol 2025-106) are uploaded in the OSF project under ‘Compliance & Validation’; the Policy & Practice article is uploaded under ‘Evidence Base”. All annexes (Indicator Dictionary, Dashboards, Artifacts, and the ToC Diagram) are positioned after the reference list to enhance ease of comparison with the content of the protocol paper.