Back to Standards/Criterion 20.3.2.20
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.

20.3.2.20
Safety and performance improvement activities

Blood Bank Compatibility Protocol 3.2

The Pathology and Clinical Laboratory Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for blood bank compatibility.

Compliance Criteria

  • 1Approved standard operating procedure for blood bank compatibility reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day blood bank compatibility 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. Salmiah Zakaria on 20 Jan 2026

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

"The department has established comprehensive operational policies for blood bank compatibility. 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.

SZ
Person-in-ChargeManager, Diagnostic Laboratory 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

On-site tracer identified that blood bank compatibility procedures in Pathology and Clinical Laboratory Services are not operationalized. Required audit records and surveillance evidence could not be produced.

Formulate and approve a formal operational framework for blood bank compatibility with designated staff competencies and active surveillance.

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