Back to Standards/Criterion 23A.2.1.15
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorPartially met
Dr Noraini AhmadRecorded 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.

23A.2.1.15
Policies and procedures

Bereavement Support Protocol 2.1

The Mortuary Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for bereavement support.

Compliance Criteria

  • 1Approved standard operating procedure for bereavement support reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day bereavement support 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. Harlina binti Mansor on 15 Jan 2026

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

"The department has established comprehensive operational policies for bereavement support. 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.

HM
Person-in-ChargeMortuary Services Supervisor
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Noraini Ahmad (Allied Health & Clinical Support Surveyor)

Surveyor Rating

Committed 15 Apr 2026

Staff interviews during tracer challenge indicated uneven adherence to bereavement support protocols during weekend coverage, despite available departmental guidelines.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for bereavement support.

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