Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
Newborn Delivery Protocol Protocol 4.2
The Labour Delivery Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for newborn delivery protocol.
Compliance Criteria
- 1Approved standard operating procedure for newborn delivery protocol reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day newborn delivery protocol 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 Matron Norliah binti Hashim on 24 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for newborn delivery protocol. 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 newborn delivery protocol reviewed within the last 3 years
- Designated qualified personnel assigned to monitor day-to-day newborn delivery protocol 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.