Surveyor Consensus & Allocation Dispute
Team leader to resolveLead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Mr Ganesh PillaiRecorded 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.
19.1.1Core StandardSafety Standard
Special requirementsDiagnostic Imaging Radiation Safety and Licences
Diagnostic Imaging operates under valid AELB Class C licences, ensuring radiation shielding, staff dosimetry and ALARA radiation protection protocols.
Compliance Criteria
- 1Valid Atomic Energy Licensing Board (AELB) licences displayed for all X-ray and CT equipment
- 2Qualified Radiation Protection Officer (RPO) appointed and actively supervising
- 3Quarterly personal dosimeter (TLD badge) monitoring records and dose limit audits
- 4Lead aprons, thyroid shields and gonad shields tested annually for structural integrity
Hospital Self-Rating
Rated by En. Shahril bin Hassan on 15 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Radiology equipment operates under current AELB licences with active RPO oversight, TLD badge dose monitoring and intact protective lead aprons."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Valid Atomic Energy Licensing Board (AELB) licences displayed for all X-ray and CT equipment
- Qualified Radiation Protection Officer (RPO) appointed and actively supervising
- Quarterly personal dosimeter (TLD badge) monitoring records and dose limit audits
- Lead aprons, thyroid shields and gonad shields tested annually for structural integrity
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-19-002Radiation Safety
Radiation Protection Apparel Annual Fluoroscopic Integrity Inspection Compliance
3 readings recorded (Target: >= 100%)
SH
Person-in-ChargeSenior Radiographer & Imaging Supervisor
Head of DepartmentChief Executive Officer
RI
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)