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.
5.1.1Core Standard
Organisation and managementNursing Administration and Leadership
Nursing services are led by qualified nursing leaders who direct clinical nursing care, professional standards and staffing resource allocation.
Compliance Criteria
- 1Director of Nursing and Nurse Managers possess valid Annual Practising Certificates (APC)
- 2Nursing operational policies, guidelines and procedure manuals reviewed every three years
- 3Monthly nursing executive and sister meetings with documented minutes
- 4Nurse staffing rostering system ensuring clinical skill mix across shifts
Hospital Self-Rating
Rated by Matron Norliah binti Hashim on 11 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Nursing administration maintains valid APC verification for all nursing personnel. Nursing clinical guidelines are reviewed every three years."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Monthly nursing executive and sister meetings with documented minutes
- Nurse staffing rostering system ensuring clinical skill mix across shifts
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
PolicyAcceptedScore: 93/100
Nursing Clinical Governance Manual & Professional Practice Guidelines
140 pages · ENValid: 2024-01-01 to 2027-01-01
NH
Person-in-ChargeDirector of Nursing
Head of DepartmentChief Executive Officer
RI
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)