Back to Standards/Criterion 04.4.3.25
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorNot applicable
Mr Ganesh PillaiRecorded 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.

04.4.3.25
Facilities and equipment

Operator Competency Protocol 4.3

The Biomedical Engineering Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for operator competency.

Compliance Criteria

  • 1Approved standard operating procedure for operator competency reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day operator competency 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 25 Jan 2026

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

"The department has established comprehensive operational policies for operator competency. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."

AccrediSense Intelligence
unsupported

No evidence documents attached to substantiate this self-assessment claim.

Unverified criteria:
  • Approved standard operating procedure for operator competency reviewed within the last 3 years
  • Designated qualified personnel assigned to monitor day-to-day operator competency 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.

HO
Person-in-ChargeHead of Facilities & Biomedical Engineering
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 15 Apr 2026
Hospital: Fully met → Surveyor: Not applicableDivergent
Committed Basis for Divergence:

"Surveyor on-site verification revealed discrepancy in operator competency compliance records compared against hospital self-assessment claim."

Departmental scope verification confirms that operator competency is not applicable to the operational services provided by Biomedical Engineering Services at this facility.

None specified.

None specified.