AccrediSense
Back to Standards/Criterion 1.1.2.1
1.1.2.1Core Standard
Organisation and management

Organisational and Committee Structure

There is an approved organisational structure clearly defining lines of authority, responsibility and reporting relationships for all departments and services.

Compliance Criteria

  • 1Current organisational chart endorsed by CEO and Board
  • 2Terms of reference for hospital management and clinical governance committees
  • 3Documented committee meeting schedules and quorum requirements
  • 4Monthly committee minutes and follow-up action matrix

Hospital Self-Rating

Rated by Pn. Rohani binti Ismail on 16 Jan 2026

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

"The hospital organizational chart was updated in December 2025 following the restructuring of clinical governance committees. All 14 committee terms of reference are approved with active monthly meeting minutes."

AccrediSense Intelligence
thin

Evidence documents establish procedural intent but lack documented verification records for the current audit period.

Unverified criteria:
  • Documented committee meeting schedules and quorum requirements
  • Monthly committee minutes and follow-up action matrix
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

PolicyAcceptedScore: 88/100

Hospital Clinical Governance Committee Terms of Reference & Master Hierarchy

28 pages · ENValid: 2025-12-01 to 2027-12-01
RI
Person-in-ChargeQuality Manager
Head of DepartmentChief Executive Officer
RI
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Organizational hierarchy is clearly structured. Committee terms of reference and meeting minutes demonstrate effective clinical and administrative governance oversight.

Ensure committee action matrix tracks deadlines with named assignees across all subcommittees.

Continue regular committee governance reviews.