AccrediSense
Back to Standards/Criterion 6.1.7
6.1.7Core StandardSafety Standard
Safety and performance improvement activities

Healthcare-Associated Infection (HAI) Surveillance

Surveillance of major healthcare-associated infections is conducted with standardized CDC/NHSN case definitions and risk-adjusted benchmark rates.

Compliance Criteria

  • 1Surveillance of Surgical Site Infections (SSI) in designated index surgical procedures
  • 2Surveillance of Catheter-Associated Urinary Tract Infections (CAUTI)
  • 3Surveillance of Central Line-Associated Bloodstream Infections (CLABSI)
  • 4Ventilator-Associated Pneumonia (VAP) rate monitoring in ICU / HDU

Hospital Self-Rating

Rated by Dr. Tan Mei Ling on 16 Jan 2026

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

"Surveillance of CAUTI, CLABSI and SSI is conducted continuously using CDC/NHSN definitions with quarterly benchmarking presented to ICC."

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

Unverified criteria:
  • Surveillance of Central Line-Associated Bloodstream Infections (CLABSI)
  • Ventilator-Associated Pneumonia (VAP) rate monitoring in ICU / HDU
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

RegisterAcceptedScore: 94/100

Healthcare-Associated Infections (HAI) Surveillance Master Dossier

46 pages · ENValid: 2025-01-01 to 2026-12-31

Linked Performance Indicators (3)

PI-06-001Infection Control

Surgical Site Infection (SSI) Rate for Clean and Clean-Contaminated Surgery

18 readings recorded (Target: <= 1.5%)
PI-06-002Infection Control

Catheter-Associated Urinary Tract Infection (CAUTI) Rate

3 readings recorded (Target: <= 1.8per 1,000 catheter days)
PI-06-003Infection Control

Central Line-Associated Bloodstream Infection (CLABSI) Rate

4 readings recorded (Target: <= 1.2per 1,000 line days)
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)

Surveyor Rating

Committed 14 Apr 2026

HAI surveillance for CAUTI, CLABSI, SSI and VAP is conducted according to international definitions with benchmarked rate tracking.

Standardize post-discharge surgical site infection surveillance for day-surgery patients.

Sustain high-quality epidemiological surveillance.