6.1.1Core StandardSafety Standard
Organisation and managementInfection Control Committee and Governance
An Infection Control Committee (ICC) directs the hospital-wide infection prevention and control programme with designated infection control professionals.
Compliance Criteria
- 1Multidisciplinary ICC chaired by Medical Director / Consultant Microbiologist
- 2Dedicated full-time Infection Control Link Nurses (ICLN) appointed per ward
- 3Annual infection control work plan, budget and surveillance targets
- 4Quarterly healthcare-associated infection (HAI) surveillance reports to Board
Hospital Self-Rating
Rated by Dr. Tan Mei Ling on 12 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Infection Control Committee meets quarterly. Infection Control Link Nurses are actively monitoring ward practices and surveillance indicators."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Annual infection control work plan, budget and surveillance targets
- Quarterly healthcare-associated infection (HAI) surveillance reports to Board
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
PolicyAcceptedScore: 95/100
Infection Prevention and Control Committee Charter & Work Plan
38 pages · ENValid: 2025-01-01 to 2027-01-01
TL
Person-in-ChargeInfection Control Officer & Consultant Microbiologist
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)