Back to Standards/Criterion 17A.1.4.14
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorPartially met
Mr Ganesh PillaiRecorded 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.

17A.1.4.14
Safety and performance improvement activities

Chest Physiotherapy Protocol 1.4

The Physiotherapy Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for chest physiotherapy.

Compliance Criteria

  • 1Approved standard operating procedure for chest physiotherapy reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day chest physiotherapy 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 En. Fauzi bin Ramli on 14 Jan 2026

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

"The department has established comprehensive operational policies for chest physiotherapy. 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.

FR
Person-in-ChargeHead of Physiotherapy & Rehabilitation Services
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Audit of Physiotherapy Services logs revealed intermittent documentation for chest physiotherapy, with sampled shift handover records missing mandatory supervisory sign-offs.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for chest physiotherapy.

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