AccrediSense
Back to Standards/Criterion 1.1.3.10
1.1.3.10New in the 7th Edition
Special requirements

Information Technology Continuity and Cyber Resilience

The facility establishes and tests an Information Technology Disaster Recovery and Business Continuity Plan ensuring resilience of clinical and hospital data systems.

Compliance Criteria

  • 1Documented IT Business Continuity and Disaster Recovery Plan
  • 2Off-site encrypted data backup protocol verified daily
  • 3Annual simulated failover drill for hospital information system
  • 4Staff SOP for manual paper downtime procedures in clinical areas

Hospital Self-Rating

Rated by En. Azman bin Yahya on 20 Jan 2026

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

"The IT Business Continuity Plan has been documented and off-site cloud backups are verified daily. Downtime forms and clinical workflows are established in each ward station."

AccrediSense Intelligence
thin

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

Unverified criteria:
  • Annual simulated failover drill for hospital information system
  • Staff SOP for manual paper downtime procedures in clinical areas
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

PolicyPartialScore: 78/100Unconfirmed link

IT Disaster Recovery & Business Continuity Framework

42 pages · ENValid: 2024-06-01 to 2027-06-01
AY
Person-in-ChargeManager, Information Technology & Digital Health
Head of DepartmentQuality Manager
RI
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 14 Apr 2026
Hospital: Fully met → Surveyor: Partially metDivergent
Committed Basis for Divergence:

"The hospital self-assessed as Fully Met based on off-site backup logs, but compliance criteria explicitly mandate an annual simulated failover drill which has not been completed within the past 12 months."

The IT disaster recovery documentation is comprehensive and daily off-site backups are performed. However, the last simulated full failover drill for the clinical EMR system was conducted over 18 months ago, exceeding annual policy requirements.

Schedule and execute an annual full simulated failover drill for the hospital information system with downtime workflow testing in acute wards.

Conduct simulated IT disaster recovery drill and document failover recovery time objectives.