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Back to Standards/Criterion 09E.3.2.20
09E.3.2.20
Safety and performance improvement activities

Surgical Infection Control Protocol 3.2

The Orthopaedic Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for surgical infection control.

Compliance Criteria

  • 1Approved standard operating procedure for surgical infection control reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day surgical infection control 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 20 Jan 2026

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

"The department has established comprehensive operational policies for surgical infection control. 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.

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

Surveyor Rating

Committed 14 Apr 2026

Review of surgical infection control monitoring files in Orthopaedic Services identified overdue quarterly audits and incomplete corrective action verification.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for surgical infection control.

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