Readiness Matrix

Hospital-wide accreditation readiness across 31 licensed standards, Core criteria gates, and MSQH areas of concern.

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

Service Standards Readiness Matrix

31 licensed standards × 6 MSQH areas of concern · Coloured by lowest authoritative rating

Standard	Organisation and management	Human resource development and management	Policies and procedures	Facilities and equipment	Safety and performance improvement activities	Special requirements
01Governance, Leadership and Direction
02Environmental and Safety Services
03Facility Management and Safety
04Biomedical Engineering Services
05Nursing Services
06Prevention and Control of Infection
07Patient and Family Rights
08Health Information and Medical Records
09AGeneral Medical Services
09BGeneral Surgical Services
09CObstetric and Gynaecological Services
09DPaediatric Services
09EOrthopaedic Services
09FAnaesthetic Services
10Operating Suite Services
11Ambulatory Care Services
12ACritical Care Services - General / ICU
12BCritical Care Services - Coronary Care / CCU	✕	✕	✕	✕	✕	✕
12CCritical Care Services - Neonatal Intensive Care / NICU	✕	✕	✕	✕	✕	✕
12DCritical Care Services - Paediatric Intensive Care / PICU	✕	✕	✕	✕	✕	✕
12ECritical Care Services - Cardiothoracic ICU	✕	✕	✕	✕	✕	✕
12FCritical Care Services - Burns Unit	✕	✕	✕	✕	✕	✕
13Labour Delivery Services
14Emergency Medical and Trauma Services
15Dietary and Food Services
16Central Sterile Supply Services (CSSD)
17APhysiotherapy Services
17BOccupational Therapy Services
17CSpeech Language Therapy Services	✕	✕	✕	✕	✕	✕
17DClinical Psychology Services	✕	✕	✕	✕	✕	✕
17EAudiology Services	✕	✕	✕	✕	✕	✕
17FPodiatry Services	✕	✕	✕	✕	✕	✕
18Pharmacy Services
19Diagnostic Imaging Services
20Pathology and Clinical Laboratory Services
21Linen and Laundry Services
22Housekeeping and Cleaning Services
23AMortuary Services
23BForensic Pathology and Medico-Legal Mortuary Services	✕	✕	✕	✕	✕	✕
24General Administration and Support Services
25Blood Transfusion Services
26Nuclear Medicine Services	✕	✕	✕	✕	✕	✕
27Radiotherapy and Oncology Daycare Services	✕	✕	✕	✕	✕	✕
28Haemodialysis Services	✕	✕	✕	✕	✕	✕
29Assisted Reproductive Technology (ART) Services	✕	✕	✕	✕	✕	✕
30Cellular Therapy and Bone Marrow Transplant Services	✕	✕	✕	✕	✕	✕
31Dental and Maxillofacial Surgery Services	✕	✕	✕	✕	✕	✕
32Hyperbaric Oxygen Therapy Services	✕	✕	✕	✕	✕	✕
33Clinical Research and Trial Services	✕	✕	✕	✕	✕	✕
34Medical Transportation and Inter-Facility Ambulance Services	✕	✕	✕	✕	✕	✕
35Information and Communication Technology (ICT) Services	✕	✕	✕	✕	✕	✕

Divergence by Standard

23 criteria diverged

Standards where hospital self-assessment differs from authoritative surveyor findings.

Hospital over-rating concentrated in 01, 06, 07

01Governance, Leadership and Direction

12 divergences(27 criteria)

06Prevention and Control of Infection

2 divergences(23 criteria)

08Health Information and Medical Records

2 divergences(20 criteria)

02Environmental and Safety Services

1 divergence(21 criteria)

03Facility Management and Safety

1 divergence(15 criteria)

04Biomedical Engineering Services

1 divergence(20 criteria)

07Patient and Family Rights

1 divergence(20 criteria)

09BGeneral Surgical Services

1 divergence(15 criteria)

09CObstetric and Gynaecological Services

1 divergence(15 criteria)

09DPaediatric Services

1 divergence(15 criteria)

Person in Charge (PiC) Readiness & Drill Register

Surveyor tracer calibration

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

Dato' Dr. Hj Razak Ismail

Due for drill

Chief Executive Officer · Executive Management

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

Drill with Jessie

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

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

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

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.