6.1.4Core StandardSafety Standard
Policies and proceduresStandard Precautions and Hand Hygiene Compliance
Standard precautions are practiced throughout the facility, supported by alcohol-based hand rub availability and systematic hand hygiene compliance audits.
Compliance Criteria
- 1Accessible alcohol hand rub dispensers at point of care and patient bedsides
- 2Staff training on WHO 5 Moments for Hand Hygiene during orientation and annually
- 3Quarterly hand hygiene direct observation compliance audits exceeding 85% target
- 4Feedback of audit scores to clinical departments and executive leadership
Hospital Self-Rating
Rated by Dr. Tan Mei Ling on 14 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Hand hygiene compliance audits are conducted quarterly across all clinical departments with the latest hospital compliance reaching 88.4%."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Quarterly hand hygiene direct observation compliance audits exceeding 85% target
- Feedback of audit scores to clinical departments and executive leadership
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
Audit reportAcceptedScore: 92/100
WHO 5 Moments Hand Hygiene Direct Observation Audit Dossier (2025)
34 pages · ENValid: 2025-01-01 to 2026-12-31
Linked Performance Indicators (1)
PI-01-007Infection Control
Hospital-wide Direct Observation Hand Hygiene Compliance Rate
6 readings recorded (Target: >= 85%)
TL
Person-in-ChargeInfection Control Officer & Consultant Microbiologist
Head of DepartmentDirector of Nursing
NH
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)