Back to Standards/Criterion 09F.2.3.17
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.

09F.2.3.17
Special requirements

Intra-operative Monitoring Protocol 2.3

The Anaesthetic Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for intra-operative monitoring.

Compliance Criteria

  • 1Approved standard operating procedure for intra-operative monitoring reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day intra-operative monitoring 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. Lim Chee Keong on 17 Jan 2026

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

"The department has established comprehensive operational policies for intra-operative monitoring. 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.

LK
Person-in-ChargeHead of Anaesthesia & Operating Theatres
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 intra-operative monitoring lacks continuous trend analysis and formal closure evidence on identified non-conformances.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for intra-operative monitoring.

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