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Back to Standards/Criterion 6.1.13.1
6.1.13.1Safety StandardNew in the 7th Edition
Facilities and equipment

Environmental Cleaning and Disinfection Surveillance

Environmental cleaning protocols, chemical disinfectant efficacy testing and routine ATP / microbiological validation ensure high-touch surface hygiene.

Compliance Criteria

  • 1Approved hospital environmental cleaning and terminal disinfection SOP
  • 2Fluorescent marker / ATP bioluminescence cleaning audit programme in high-risk zones
  • 3Periodic environmental microbiological swabbing in theatres, ICU and endoscopy
  • 4Corrective re-cleaning protocol when cleanliness benchmarks are not met

Hospital Self-Rating

Rated by Dr. Tan Mei Ling on 20 Jan 2026

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

"Environmental cleaning audits and ATP surface bioluminescence verification are performed regularly in operating rooms and acute wards."

AccrediSense Intelligence
thin

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

Unverified criteria:
  • Periodic environmental microbiological swabbing in theatres, ICU and endoscopy
  • Corrective re-cleaning protocol when cleanliness benchmarks are not met
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

Audit reportPartialScore: 76/100

Environmental ATP Bioluminescence Surface Hygiene Audit Reports

28 pages · ENValid: 2025-06-01 to 2026-06-01

Linked Performance Indicators (1)

PI-22-001Housekeeping & Hygiene

Environmental Surface Cleanliness ATP Bioluminescence Swab Compliance Rate

18 readings recorded (Target: >= 90%)
TL
Person-in-ChargeInfection Control Officer & Consultant Microbiologist
Head of DepartmentHead of Facilities & Biomedical Engineering
HO
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 15 Apr 2026
Hospital: Fully met → Surveyor: Partially metDivergent
Committed Basis for Divergence:

"The hospital self-assessed as Fully Met based on current Q1 2026 records, but historical documentation reveals a two-month audit gap in Q4 2025 in acute areas that was not formally rectified with compensatory testing."

Environmental cleaning SOPs and ATP surface testing are implemented. However, audit records in High Dependency Unit showed that environmental swabbing was omitted for two consecutive months in Q4 2025 due to reagent shortages.

Ensure continuous buffer stock of ATP testing reagents and establish a formal corrective action protocol when cleaning benchmark scores drop.

Maintain uninterrupted environmental cleaning validation audits across all acute care units.