1.2.2.1Core StandardSafety Standard
Human resource development and managementCredentialing and Privileging of Medical Practitioners
A formal credentialing and privileging system is established for all medical practitioners ensuring practice within approved scopes of clinical competence.
Compliance Criteria
- 1Medical Credentialing and Privileging Committee established with clear TOR
- 2Primary source verification of medical degrees and National Specialist Register (NSR) status
- 3Documented clinical privilege delineation forms signed and renewed biennially
- 4Emergency and temporary privilege protocols defined and monitored
Hospital Self-Rating
Rated by Dr. Azmi Razak on 10 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The Credentialing and Privileging Committee meets quarterly. All 48 consultant specialists have verified NSR registrations and signed scope of practice privilege forms on file."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Documented clinical privilege delineation forms signed and renewed biennially
- Emergency and temporary privilege protocols defined and monitored
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
RegisterAcceptedScore: 95/100
Medical Credentialing and Privileging Master Register (2025/2026)
52 pages · ENValid: 2025-01-01 to 2026-12-31
AR
Person-in-ChargeHead of Clinical Services & Consultant Physician
Head of DepartmentChief Executive Officer
RI
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)