10.3.1.19
Special requirementsSterility Assurance Protocol 3.1
The Operating Suite Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for sterility assurance.
Compliance Criteria
- 1Approved standard operating procedure for sterility assurance reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day sterility assurance compliance
- 3Regular documentation audits and evidence of corrective action implementation
- 4Staff training records and competency assessments maintained in the department
Hospital Self-Rating
Rated by Dr. Lim Chee Keong on 19 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for sterility assurance. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Approved standard operating procedure for sterility assurance reviewed within the last 3 years
- Designated qualified personnel assigned to monitor day-to-day sterility assurance compliance
- Regular documentation audits and evidence of corrective action implementation
- Staff training records and competency assessments maintained in the department
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.
LK
Person-in-ChargeHead of Anaesthesia & Operating Theatres
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)