Back to Standards/Criterion 06.4.3.25
06.4.3.25
Special requirements

Environmental Cleanliness Protocol 4.3

The Prevention and Control of Infection department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for environmental cleanliness.

Compliance Criteria

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

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

"The department has established comprehensive operational policies for environmental cleanliness. 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.

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)

Surveyor Rating

Committed 15 Apr 2026

Surveyor assessment revealed complete absence of structured monitoring logs and verified staff competency assessments for environmental cleanliness in Prevention and Control of Infection.

Formulate and approve a formal operational framework for environmental cleanliness with designated staff competencies and active surveillance.

Develop mandatory SOP, assign operational indicator oversight, and conduct staff training within 60 days.