Criterion 4.1.3 — AccrediSense

Surveyor Consensus & Allocation Dispute

Team leader to resolve

Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead

Rating SurveyorFully 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.

4.1.3Core StandardSafety Standard

Facilities and equipment

Planned Preventive Maintenance (PPM) of Medical Equipment

Medical devices undergo scheduled planned preventive maintenance (PPM) and performance calibration in accordance with manufacturer specifications.

Compliance Criteria

1Annual PPM master schedule with designated calibration frequencies
2Current PPM inspection stickers attached to all active clinical devices
3PPM completion rate exceeding 95% threshold across clinical departments
4Electrical safety testing (EST) records in compliance with IEC 62353

Hospital Self-Rating

Rated by En. Hakim Osman on 16 Jan 2026

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

"Planned preventive maintenance achieved 97.2% overall compliance in 2025. Electrical safety testing is performed on all active clinical assets."

AccrediSense Intelligence

thin

Evidence documents establish procedural intent but lack documented verification records for the current audit period.

Unverified criteria:

PPM completion rate exceeding 95% threshold across clinical departments
Electrical safety testing (EST) records in compliance with IEC 62353

Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

Audit reportAcceptedScore: 95/100

Planned Preventive Maintenance (PPM) & Electrical Safety Testing Verification

44 pages · ENValid: 2025-01-01 to 2026-12-31

Linked Performance Indicators (1)

PI-04-001Biomedical Engineering

Critical Life-Support Biomedical Equipment Planned Preventive Maintenance (PPM) Rate

18 readings recorded (Target: >= 95%)

Person-in-ChargeHead of Facilities & Biomedical Engineering

Head of DepartmentHead of Facilities & Biomedical Engineering

Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)