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Back to Standards/Criterion 03.2.2.16
03.2.2.16
Policies and procedures

Plant Operations Protocol 2.2

The Facility Management and Safety department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for plant operations.

Compliance Criteria

  • 1Approved standard operating procedure for plant operations reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day plant operations 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. Hakim Osman on 16 Jan 2026

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

"The department has established comprehensive operational policies for plant operations. 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.

HO
Person-in-ChargeHead of Facilities & Biomedical Engineering
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Review of plant operations monitoring files in Facility Management and Safety identified overdue quarterly audits and incomplete corrective action verification.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for plant operations.

Implement monthly documentation audits and review adherence rates during departmental quality meetings.