01.4.1.23
Human resource development and managementExecutive Governance Protocol 4.1
The Governance, Leadership and Direction department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for executive governance.
Compliance Criteria
- 1Approved standard operating procedure for executive governance reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day executive governance 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 23 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for executive governance. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Approved standard operating procedure for executive governance reviewed within the last 3 years
- Designated qualified personnel assigned to monitor day-to-day executive governance compliance
- Regular documentation audits and evidence of corrective action implementation
- Staff training records and competency assessments maintained in the department
Derived from AccrediSense Evidence Engine · 0 documents attached against 4 compliance criteriaGovernance disclosure (1.4.1.4)
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)