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.
5.2.3Safety Standard
Policies and proceduresClinical Handover and Structured SBAR Communication
Structured clinical handover using standardized SBAR (Situation, Background, Assessment, Recommendation) communication is practiced at all shift changes.
Compliance Criteria
- 1Standardized SBAR handover format utilized across all ward shift transitions
- 2Bedside handover involving the patient and family members where appropriate
- 3Documentation of critical diagnostic test results and pending clinical tasks
- 4Audit of nursing handover compliance and communication clarity
Hospital Self-Rating
Rated by Matron Norliah binti Hashim on 17 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Bedside nursing handovers follow the standardized SBAR framework. Audits show 96% compliance with structured shift communication."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Documentation of critical diagnostic test results and pending clinical tasks
- Audit of nursing handover compliance and communication clarity
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
PolicyAcceptedScore: 92/100
Structured SBAR Clinical Handover Protocol & Ward Observation Audits
20 pages · ENValid: 2025-04-01 to 2028-04-01
NH
Person-in-ChargeDirector of Nursing
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)