Surveyor Consensus & Allocation Dispute
Team leader to resolveLead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Pn Zaiton AbdullahRecorded finding during tracer inspectionAwaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
16.2.1Core StandardSafety Standard
Policies and proceduresSterilisation Monitoring and Biological Indicators
Every sterilisation cycle is monitored using physical, chemical (Class 5 / Class 6) and biological indicators (Geobacillus stearothermophilus) with recorded results.
Compliance Criteria
- 1Physical cycle parameters (time, temperature, pressure) printouts reviewed per load
- 2Chemical integrator strips inside every instrument pack and external indicator tape
- 3Daily biological indicator testing for steam sterilizers and every implant load
- 4Sterilisation batch logs and load release sign-off by qualified technician
Hospital Self-Rating
Rated by Pn. Zainab binti Sulaiman on 17 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Every autoclave cycle is verified with physical parameters, Class 5 chemical integrators and daily biological indicator monitoring."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Physical cycle parameters (time, temperature, pressure) printouts reviewed per load
- Chemical integrator strips inside every instrument pack and external indicator tape
- Daily biological indicator testing for steam sterilizers and every implant load
- Sterilisation batch logs and load release sign-off by qualified technician
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.
Linked Performance Indicators (1)
PI-16-001Sterilisation & CSSD
Central Sterile Supply Department (CSSD) Autoclave Biological Indicator Pass Rate
18 readings recorded (Target: >= 100%)
ZS
Person-in-ChargeCSSD Supervisor
Head of DepartmentInfection Control Officer & Consultant Microbiologist
TL
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)