AccrediSense
Survey day 2 of 4. Four-Year Accreditation is currently blocked by 1 Core criterion.
Core Standards GateBlocked
47 / 48

1 failing core criterion blocks 4-Year Accreditation.

Safety Standards GatePass (100%)
22 / 22

All 22 critical patient safety criteria verified met.

Overall Progress91.0%
463 / 509

16 not yet rated · Supporting volume metric.

1.2.7.1Workforce Physical, Mental and Spiritual Wellbeing (Staff physical, mental and spiritual wellbeing)

Rated Not met · Risk: High · Surveyor: Dr Mohd Anis Haron

View criterion record
AccrediSense Intelligence

Executive Readiness Assessment: Delayed

Hospital Seri Damai holds 91.0% overall compliance. However, Four-Year Accreditation is strictly gated by mandatory core and safety standards. While document deficits on operational indicators require 2 to 4 weeks of retrospective audit trails, Core criterion 1.2.7.1 requires a comprehensive staff wellbeing policy to be written, approved, implemented and evidenced across clinical departments before compliance can be substantiated.

Derived from AccrediSense Readiness Engine · 509 criteria audit trail and 4-Year gate statusGovernance disclosure (1.4.1.4)

Active SIQ Statutory Obligation Clocks

Strict 4-stage closure timeline
SIQ-2026-003Corrective Action Plan

Operating theater surgical timeout documentation discrepancy in Orthopedic OT 2

Triggered by PI-06-003 · RCA Lead: hs-lim

52 hours remaining
Track SIQ
SIQ-2026-007SIQ Form Submission

Post-operative surgical site infection cluster in General Surgery Ward 3B

Triggered by PI-06-003 · RCA Lead: hs-tan

52 hours remaining
Track SIQ

Evidence Deficit Register (5 categories)

Counts reported directly · No aggregate percentages

1 indicator has no data at all — PI-01-019

Clinical indicator configured without uploaded monthly readings.

2 indicators have data but no analysis

Readings entered without mandatory 4-level clinical analysis dossiers.

2 indicators breached without a documented action plan

Target breaches on PI-06-003 and PI-06-014 require immediate corrective actions.

1 indicator's denominator does not match its specification

PI-05-001 medication transfer count discrepancy identified.

4 evidence documents are more than 12 months old

Expired policies and SOPs attached to active hospital criteria.

Person in Charge (PiC) Readiness & Drill Register

Surveyor tracer calibration
AK

Pn. Aishah Kamal

Action required

Head of Human Resources · Human Resources Management

Could not explain her indicator yesterday during surveyor tracer challenge. Urgent coaching required.

Drill with Jessie
RI

Dato' Dr. Hj Razak Ismail

Due for drill

Chief Executive Officer · Executive Management

0 indicator(s) assigned · Last drill: Never drilled

Drill with Jessie
FK

Pn. Faridah binti Kassim

Due for drill

Nurse Unit Manager, Intensive Care Unit · Intensive Care Unit (ICU)

1 indicator(s) assigned · Last drill: Never drilled

Drill with Jessie
ZA

En. Mohd Zaki Ariffin

Due for drill

Safety, Health and Environment Officer · Occupational Safety & Health Unit

1 indicator(s) assigned · Last drill: 2026-02-14

Drill with Jessie
SH

En. Shahril bin Hassan

Due for drill

Senior Radiographer & Imaging Supervisor · Diagnostic Imaging Services

2 indicator(s) assigned · Last drill: Never drilled

Drill with Jessie

Live Survey Activity Feed

Real-time cross-authority audit trail
  • HS
    Validated operational SOP and clinical pathway documentation for Criterion 20.3.1.19.13:07

    Actor: hs-azmi (hospital) · Reviewed accreditation readiness record

  • HS
    Reviewed quarterly audit compliance records against Criterion 12A.4.2.24.10:06

    Actor: hs-rohani (hospital) · Reviewed accreditation readiness record

  • HS
    Uploaded evidence document doc-05: "Bomba Fire Safety Certificate (Sijil Perakuan Bomba)" to library.13:30

    Actor: hs-zaki (hospital) · Uploaded evidence document

  • HS
    Uploaded evidence document doc-04: "Private Healthcare Facilities and Services Act 1998 (Act 586) Operating Licence" to library.10:00

    Actor: hs-rohani (hospital) · Uploaded evidence document

  • HS
    Updated departmental corrective action tracking register for Criterion 19.2.1.15.09:37

    Actor: hs-rohani (hospital) · Reviewed accreditation readiness record

  • HS
    Uploaded evidence document doc-01: "Hospital Strategic Plan & Core Values Charter (2024–2028)" to library.12:30

    Actor: hs-rohani (hospital) · Uploaded evidence document

  • HS
    Validated operational SOP and clinical pathway documentation for Criterion 09F.4.3.25.15:22

    Actor: hs-hakim (hospital) · Reviewed accreditation readiness record

  • HS
    Completed internal self-assessment verification check for Criterion 14.2.4.18.14:35

    Actor: hs-hakim (hospital) · Reviewed accreditation readiness record

  • HS
    Completed internal self-assessment verification check for Criterion 10.1.4.14.14:05

    Actor: hs-rohani (hospital) · Reviewed accreditation readiness record

  • HS
    Cross-referenced evidence attachment validity and expiry dates for Criterion 09D.2.4.18.12:52

    Actor: hs-fauzi (hospital) · Reviewed accreditation readiness record

  • HS
    Conducted safety drill DRL-2025-002: "Code Blue Adult Cardiopulmonary Resuscitation Drill (Ward 4A)".11:30

    Actor: hs-azmi (hospital) · Conducted hospital safety drill

  • HS
    Reviewed quarterly audit compliance records against Criterion 08.2.4.18.12:36

    Actor: hs-rohani (hospital) · Reviewed accreditation readiness record