06.3.4.22
Policies and proceduresSurveillance Protocols Protocol 3.4
The Prevention and Control of Infection department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for surveillance protocols.
Compliance Criteria
- 1Approved standard operating procedure for surveillance protocols reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day surveillance protocols 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 Dr. Tan Mei Ling on 22 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for surveillance protocols. 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 surveillance protocols reviewed within the last 3 years
- Designated qualified personnel assigned to monitor day-to-day surveillance protocols 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.
TL
Person-in-ChargeInfection Control Officer & Consultant Microbiologist
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)