1.4.1.4New in the 7th Edition
Policies and proceduresGovernance and Ethical Deployment of Digital and AI Tools
The healthcare facility establishes formal governance, risk mitigation, clinical validation and staff competency frameworks for digital and artificial intelligence systems.
Compliance Criteria
- 1Formal clinical relevance and technical feasibility assessment before digital system deployment
- 2Documented multidisciplinary clinical stakeholder engagement and sign-off
- 3Cybersecurity, patient data privacy and ethical risk impact assessment
- 4Staff training records, continuous monitoring and algorithm performance auditing
- 5Ensured equitable access and validated non-digital manual alternative pathways
Hospital Self-Rating
Rated by En. Azman bin Yahya on 25 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Digital governance guidelines are established covering technical feasibility, data privacy and clinical safety validation for automated clinical tools."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Formal clinical relevance and technical feasibility assessment before digital system deployment
- Documented multidisciplinary clinical stakeholder engagement and sign-off
- Cybersecurity, patient data privacy and ethical risk impact assessment
- Staff training records, continuous monitoring and algorithm performance auditing
- Ensured equitable access and validated non-digital manual alternative pathways
Derived from AccrediSense Evidence Engine · 0 documents attached against 5 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.
AY
Person-in-ChargeManager, Information Technology & Digital Health
Head of DepartmentQuality Manager
RI
Surveyor Authority Pane