Back to Standards/Criterion 24.4.1.23
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorPartially 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.

24.4.1.23New in the 7th Edition
Human resource development and management

Procurement Oversight Protocol 4.1

The General Administration and Support Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for procurement oversight.

Compliance Criteria

  • 1Approved standard operating procedure for procurement oversight reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day procurement oversight 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. Rohani binti Ismail on 23 Jan 2026

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

"The department has established comprehensive operational policies for procurement oversight. 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.

RI
Person-in-ChargeQuality Manager
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 15 Apr 2026

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

Establish continuous supervisory sign-off audits and enforce documented shift compliance for procurement oversight.

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