Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
Procedure Room Safety Protocol 4.2
The Ambulatory Care Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for procedure room safety.
Compliance Criteria
- 1Approved standard operating procedure for procedure room safety reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day procedure room safety 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. Azmi Razak on 24 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for procedure room safety. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."
No evidence documents attached to substantiate this self-assessment claim.
- Approved standard operating procedure for procedure room safety reviewed within the last 3 years
- Designated qualified personnel assigned to monitor day-to-day procedure room safety compliance
- Regular documentation audits and evidence of corrective action implementation
- Staff training records and competency assessments maintained in the department
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.