Surveyor Consensus & Allocation Dispute
Team leader to resolveLead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Pn Zaiton AbdullahRecorded 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.
2.2.3Safety Standard
Organisation and managementDisaster and Mass Casualty Management Plan
A comprehensive Hospital Disaster and Mass Casualty Incident Plan is maintained, regularly exercised and coordinated with external emergency services.
Compliance Criteria
- 1Approved Major Incident and External Mass Casualty Plan
- 2Designated emergency triage and decontamination staging areas
- 3Emergency communication tree and secondary communication equipment
- 4Annual multi-agency disaster simulation drill report with documented action items
Hospital Self-Rating
Rated by Dr. Nurul Huda on 20 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The Hospital Disaster Plan provides clear mass casualty triage and emergency staging workflows. Multi-agency simulation drill was conducted in October 2025."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Emergency communication tree and secondary communication equipment
- Annual multi-agency disaster simulation drill report with documented action items
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
PolicyAcceptedScore: 93/100
Hospital Disaster & Mass Casualty Incident Operational Protocol
48 pages · ENValid: 2025-08-01 to 2028-08-01
NH
Person-in-ChargeEmergency Medicine Specialist
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)