Back to Standards/Criterion 09D.1.3.13
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorPartially met
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.

09D.1.3.13New in the 7th Edition
Special requirements

Neonatal Resuscitation Protocol 1.3

The Paediatric Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for neonatal resuscitation.

Compliance Criteria

  • 1Approved standard operating procedure for neonatal resuscitation reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day neonatal resuscitation 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. Wong Wei Jun on 13 Jan 2026

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

"The department has established comprehensive operational policies for neonatal resuscitation. 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.

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

Surveyor Rating

Committed 15 Apr 2026

Departmental surveillance for neonatal resuscitation lacks continuous trend analysis and formal closure evidence on identified non-conformances.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for neonatal resuscitation.

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