1.3.2
Safety and performance improvement activitiesRisk Management and Clinical Governance Oversight
The organisation establishes a systematic risk management framework identifying, assessing, mitigating and monitoring clinical and non-clinical risks.
Compliance Criteria
- 1Hospital enterprise risk register reviewed and updated biannually
- 2Risk escalation matrix and reporting protocol to the Board of Directors
- 3Clinical incident notification and root cause analysis process
- 4Patient safety incident reporting system integrated across departments
Hospital Self-Rating
Rated by Pn. Rohani binti Ismail on 19 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The hospital enterprise risk register is maintained with regular risk assessment updates. Departmental risk assessments cover clinical and physical plant hazards."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Hospital enterprise risk register reviewed and updated biannually
- Risk escalation matrix and reporting protocol to the Board of Directors
- Clinical incident notification and root cause analysis process
- Patient safety incident reporting system integrated across departments
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