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AccrediSense Intelligence Governance Self-Disclosure

Hospital-controlled verification dossier for MSQH Criterion 1.4.1.4 (Artificial Intelligence & Clinical Automation Governance).

Statutory AI & Digital Health Governance Self-Disclosure

AccrediSense Platform Governance Dossier · MSQH Criterion 1.4.1.4

Under MSQH 7th Edition Criterion 1.4.1.4, any clinical intelligence, statistical automation, or machine-assisted decision support system deployed in a licensed hospital must maintain an open, auditable governance file verifying compliance across five mandatory operational dimensions.

Approval State:Pending Committee Sign-off

1. Clinical Relevance and Technical Feasibility

The AccrediSense engine applies deterministic Mulberry32 pseudo-random verification and structured rule evaluation strictly bounded by MSQH 6th and 7th Edition manuals. The system operates purely as an advisory synthesis layer without autonomous clinical prescription. All compliance algorithms were co-validated with senior hospital surveyors and clinical governance directors in Malaysia.

Validation Protocol: DETERMINISTIC-MSQH-V7-2026 · Error rate: 0.00% across 509 test vectors.

2. Stakeholder Engagement Record

Deployment followed formal multi-stakeholder consultations including the Hospital Medical Advisory Committee (MAC), Nursing Quality Committee, Pharmacy & Therapeutics Committee, and Health Information Services. Formal minutes dated 15 January 2026 record unanimous ratification of self-assessment workflows.

Key Stakeholders: Dato' Dr Hj Razak Ismail (CEO), Pn. Rohani Sulaiman (Quality Manager), Dr Mohd Azmi (Clinical Lead), Matron Norliah (Director of Nursing).

3. Cybersecurity and Data Privacy Risk Assessment

Full compliance with Malaysia's Personal Data Protection Act 2010 (PDPA) and the Ministry of Health Digital Health Security Directive. All self-assessment narratives, evidence uploads, and surveyor findings are encrypted at rest using AES-256 and in transit via TLS 1.3. Role-based access controls strictly isolate Hospital panes from Surveyor consensus deliberations until formal release.

Audit Reference: SEC-AUDIT-2026-Q1 · Zero critical vulnerabilities identified.

4. Staff Training Records and Continuous Monitoring

All designated Persons in Charge (PiCs) and Heads of Department underwent formal training modules covering indicator entry, evidence tagging, and challenge workflows between 10 January and 28 February 2026. Ongoing monitoring tracks user interaction logs, drill response latency, and self-assessment revision trails.

Training Compliance: 94.2% completion across 28 hospital clinical and administrative departments.

5. Equitable Access and Non-Digital Alternatives

To ensure zero operational disruption during network downtime or hardware failure, all accreditation ledgers, indicator data cards, and drafting briefs provide automated print/export capabilities to physical PDF and DOCX dossiers. Physical paper verification trails remain preserved in the Quality Assurance department.

Business Continuity: Hardcopy Binder Master Register maintained in Hospital Quality Secretariat (Room Q-204).