01.3.2.20
Safety and performance improvement activitiesStatutory Compliance Protocol 3.2
The Governance, Leadership and Direction department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for statutory compliance.
Compliance Criteria
- 1Approved standard operating procedure for statutory compliance reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day statutory compliance compliance
- 3Regular documentation audits and evidence of corrective action implementation
- 4Staff training records and competency assessments maintained in the department
Hospital Self-Rating
Rated by Pn. Rohani binti Ismail on 20 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for statutory compliance. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."
Evidence Documents (0)
A criterion with no document reads as unevidenced to the survey team.
Attach relevant hospital policies, registers, audit reports, or training records.
RI
Person-in-ChargeQuality Manager
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)