Back to Standards/Criterion 16.2.1.15
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorNot applicable
Pn Zaiton AbdullahRecorded finding during tracer inspection

Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.

16.2.1.15
Policies and procedures

Clean Storage Protocols Protocol 2.1

The Central Sterile Supply Services (CSSD) department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for clean storage protocols.

Compliance Criteria

  • 1Approved standard operating procedure for clean storage protocols reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day clean storage protocols 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. Zainab binti Sulaiman on 15 Jan 2026

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

"The department has established comprehensive operational policies for clean storage protocols. 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.

ZS
Person-in-ChargeCSSD Supervisor
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)

Surveyor Rating

Committed 15 Apr 2026

Departmental scope verification confirms that clean storage protocols is not applicable to the operational services provided by Central Sterile Supply Services (CSSD) at this facility.

None specified.

None specified.