Back to Standards/Criterion 02.4.3.25
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorNot applicable
Pn Zaiton AbdullahRecorded finding during tracer inspection

Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.

02.4.3.25
Human resource development and management

Facility Protection Protocol 4.3

The Environmental and Safety Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for facility protection.

Compliance Criteria

  • 1Approved standard operating procedure for facility protection reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day facility protection 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 En. Mohd Zaki Ariffin on 25 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"The department has established comprehensive operational policies for facility protection. 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.

ZA
Person-in-ChargeSafety, Health and Environment Officer
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)

Surveyor Rating

Committed 15 Apr 2026

Departmental scope verification confirms that facility protection is not applicable to the operational services provided by Environmental and Safety Services at this facility.

None specified.

None specified.