Back to Standards/Criterion 03.3.2.20
03.3.2.20
Organisation and management

Space Optimization Protocol 3.2

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

Compliance Criteria

  • 1Approved standard operating procedure for space optimization reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day space optimization 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 20 Jan 2026

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

"The department has established comprehensive operational policies for space optimization. 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
Hospital: Partially met → Surveyor: Fully metDivergent
Committed Basis for Divergence:

"The hospital self-rated Partially Met conservatively during internal freeze; surveyor sampling of recent quarterly logs verified that space optimization compliance is fully established in Facility Management and Safety."

Documented records and staff interviews in Facility Management and Safety substantiate consistent execution of space optimization workflows across clinical shifts.

None specified.

None specified.