Back to Standards/Criterion 16.2.4.18
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorPartially met
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.

16.2.4.18
Special requirements

Sterilisation Batch Release Protocol 2.4

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

Compliance Criteria

  • 1Approved standard operating procedure for sterilisation batch release reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day sterilisation batch release 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 18 Jan 2026

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

"The department has established comprehensive operational policies for sterilisation batch release. 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 14 Apr 2026

Audit of Central Sterile Supply Services (CSSD) logs revealed intermittent documentation for sterilisation batch release, with sampled shift handover records missing mandatory supervisory sign-offs.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for sterilisation batch release.

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