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Back to Standards/Criterion 07.2.4.18
07.2.4.18New in the 7th Edition
Policies and procedures

Feedback Resolution Protocol 2.4

The Patient and Family Rights department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for feedback resolution.

Compliance Criteria

  • 1Approved standard operating procedure for feedback resolution reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day feedback resolution 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 Pn. Rohani binti Ismail on 18 Jan 2026

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

"The department has established comprehensive operational policies for feedback resolution. 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.

RI
Person-in-ChargeQuality Manager
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Audit of Patient and Family Rights logs revealed intermittent documentation for feedback resolution, with sampled shift handover records missing mandatory supervisory sign-offs.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for feedback resolution.

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