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Back to Standards/Criterion 12A.4.2.24
12A.4.2.24Core Standard
Special requirements

Intensive Resuscitation Protocol 4.2

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

Compliance Criteria

  • 1Approved standard operating procedure for intensive resuscitation reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day intensive resuscitation 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 24 Jan 2026

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

"The department has established comprehensive operational policies for intensive resuscitation. 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 intensive resuscitation 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 intensive resuscitation.

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