AccrediSense
Back to Standards/Criterion 1.2.7.1
1.2.7.1Core StandardNew in the 7th Edition
Human resource development and management

Workforce Physical, Mental and Spiritual Wellbeing

The healthcare facility implements comprehensive programmes and policies supporting the physical, mental and spiritual wellbeing of healthcare workers.

Compliance Criteria

  • 1Approved workforce wellbeing and mental health support policy
  • 2Dedicated employee assistance programme (EAP) or formal psychological support pathway
  • 3Occupational health risk surveillance and mental health screening
  • 4Documented annual budget and operationalised wellbeing activities
  • 5Monitoring and periodic evaluation of staff wellbeing indicators

Hospital Self-Rating

Rated by Pn. Aishah Kamal on 14 Jan 2026

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

"Comprehensive staff wellbeing programmes are available including counseling services through our Employee Assistance Programme and regular fitness initiatives arranged by the recreation committee."

AccrediSense Intelligence
unsupported

Attached evidence comprises informational leaflet only; no record of implementation or departmental operationalisation register.

Unverified criteria:
  • Dedicated employee assistance programme (EAP) or formal psychological support pathway
  • Occupational health risk surveillance and mental health screening
  • Documented annual budget and operationalised wellbeing activities
  • Monitoring and periodic evaluation of staff wellbeing indicators
Derived from AccrediSense Evidence Engine · 1 document (Leaflet) against 5 compliance criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

LeafletInsufficientScore: 22/100

Staff Wellbeing & Employee Assistance Informational Leaflet

No named owner, no formal Board approval record, no implementation date, and no staff training record.

2 pages · EN, MSValid: 2024-05-01 to 2026-12-31

Linked Performance Indicators (1)

PI-01-019Human Resources & Governance

Healthcare Workforce Mental Health and Psychological Wellbeing Assessment Rate

Zero readings recorded prior to 14 April 2026.
AK
Person-in-ChargeHead of Human Resources
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 15 Apr 2026
Hospital: Fully met → Surveyor: Not metDivergent
Committed Basis for Divergence:

"The hospital self-rated Fully Met on 14 January 2026 based on an informal employee assistance leaflet. Surveyor assessment identified that no approved policy, budget allocation or active surveillance exists, and the designated Person in Charge could not explain the indicator during on-site tracer challenge."

From tracer: PiC challenge

During Tracer 3 interview with Head of Human Resources (Pn. Aishah Kamal), the person in charge was unable to explain workforce wellbeing indicator PI-01-019, stating she was unaware it had been assigned to her. The only evidence submitted is an informal employee assistance informational leaflet (scoring 22 on quality review). There is no approved workforce wellbeing policy, no documented mental health surveillance, no budget allocation, and no operationalized tracking.

Formulate and obtain Board approval for a formal Workforce Wellbeing and Mental Health Policy. Establish an operationalized Employee Assistance Programme with psychological support pathways, dedicated budget, and quarterly indicator tracking.

Establish a comprehensive, approved workforce wellbeing policy and operationalized programme with trained personnel and active indicator monitoring.