Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
Tissue Audit Protocol 4.3
The General Surgical Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for tissue audit.
Compliance Criteria
- 1Approved standard operating procedure for tissue audit reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day tissue audit 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. Azmi Razak on 25 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for tissue audit. 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.