1.3.1
Safety and performance improvement activitiesQuality Improvement and Patient Safety Programme
A structured, organisation-wide quality improvement and patient safety programme is established and led by a dedicated multidisciplinary committee.
Compliance Criteria
- 1Quality Assurance and Patient Safety Committee meeting quarterly
- 2Annual quality improvement plan with departmental key performance indicators
- 3Clinical audit framework and evidence of completed closed-loop audits
- 4Executive walkabouts and safety culture survey conducted periodically
Hospital Self-Rating
Rated by Pn. Rohani binti Ismail on 18 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The Quality Assurance Committee coordinates clinical audits and quality indicators across all services. Departmental KPI dashboards are reviewed quarterly by the executive board."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Quality Assurance and Patient Safety Committee meeting quarterly
- Annual quality improvement plan with departmental key performance indicators
- Clinical audit framework and evidence of completed closed-loop audits
- Executive walkabouts and safety culture survey conducted periodically
Derived from AccrediSense Evidence Engine · 0 documents attached against 4 compliance criteriaGovernance disclosure (1.4.1.4)
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.
RI
Person-in-ChargeQuality Manager
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority Pane