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Back to Standards/Criterion 12A.1.2.12
12A.1.2.12
Special requirements

Ventilator Care Bundles Protocol 1.2

The Critical Care Services - General / ICU department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for ventilator care bundles.

Compliance Criteria

  • 1Approved standard operating procedure for ventilator care bundles reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day ventilator care bundles 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 Pn. Faridah binti Kassim on 12 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"The department has established comprehensive operational policies for ventilator care bundles. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."

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.

FK
Person-in-ChargeNurse Unit Manager, Intensive Care Unit
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Review of ventilator care bundles monitoring files in Critical Care Services - General / ICU identified overdue quarterly audits and incomplete corrective action verification.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for ventilator care bundles.

Implement monthly documentation audits and review adherence rates during departmental quality meetings.