Back to Standards/Criterion 19.3.1.19
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorNot 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.

19.3.1.19
Organisation and management

Image Quality Assurance Protocol 3.1

The Diagnostic Imaging Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for image quality assurance.

Compliance Criteria

  • 1Approved standard operating procedure for image quality assurance reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day image quality assurance 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. Shahril bin Hassan on 19 Jan 2026

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

"The department has established comprehensive operational policies for image quality assurance. 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.

SH
Person-in-ChargeSenior Radiographer & Imaging Supervisor
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 15 Apr 2026

Surveyor assessment revealed complete absence of structured monitoring logs and verified staff competency assessments for image quality assurance in Diagnostic Imaging Services.

Formulate and approve a formal operational framework for image quality assurance with designated staff competencies and active surveillance.

Develop mandatory SOP, assign operational indicator oversight, and conduct staff training within 60 days.