Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
Instrument Tracking Protocol 3.1
The Central Sterile Supply Services (CSSD) department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for instrument tracking.
Compliance Criteria
- 1Approved standard operating procedure for instrument tracking reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day instrument tracking 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 19 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for instrument tracking. 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.