AccrediSense

Service Standards

Complete scope register of MSQH 6th & 7th Edition service standards mapped to Hospital Seri Damai operating licence.

MSQH 6th & 7th Edition Standards Scope

51 defined MSQH service standards · 31 licensed services in scope for Hospital Seri Damai · 20 out of scope

Core services

8 of 8 in scope
01Governance, Leadership and Direction
Licensed service: Governance, Leadership and Direction
5 Core1 Safety27 criteria
Not met
02Environmental and Safety Services
Licensed service: Environmental and Safety Services
3 Core4 Safety21 criteria
Not met
03Facility Management and Safety
Licensed service: Facility Management and Safety
15 criteria
Partially met
04Biomedical Engineering Services
Licensed service: Biomedical Engineering Services
2 Core1 Safety20 criteria
Partially met
05Nursing Services
Licensed service: Nursing Services
4 Core2 Safety21 criteria
Not met
06Prevention and Control of Infection
Licensed service: Prevention and Control of Infection
4 Core7 Safety23 criteria
Not met
07Patient and Family Rights
Licensed service: Patient and Family Rights
2 Core20 criteria
Partially met
08Health Information and Medical Records
Licensed service: Health Information and Medical Records
3 Core20 criteria
Partially met

Clinical services

11 of 16 in scope
09AGeneral Medical Services
Licensed service: General Medical Services
15 criteria
Not met
09BGeneral Surgical Services
Licensed service: General Surgical Services
1 Core15 criteria
Not met
09CObstetric and Gynaecological Services
Licensed service: Obstetric and Gynaecological Services
1 Core15 criteria
Partially met
09DPaediatric Services
Licensed service: Paediatric Services
15 criteria
Not met
09EOrthopaedic Services
Licensed service: Orthopaedic Services
1 Core15 criteria
Not met
09FAnaesthetic Services
Licensed service: Anaesthetic Services
1 Core15 criteria
Partially met
10Operating Suite Services
Licensed service: Operating Suite Services
15 criteria
Partially met
11Ambulatory Care Services
Licensed service: Ambulatory Care Services
1 Core14 criteria
Partially met
12ACritical Care Services - General / ICU
Licensed service: Critical Care Services - General / ICU
1 Core14 criteria
Partially met
12BCritical Care Services - Coronary Care / CCU
Out of scope: Coronary Care Unit not on licence HSD/PHF/2019/0417 (managed under general ICU)
Not Applicable
12CCritical Care Services - Neonatal Intensive Care / NICU
Out of scope: Tertiary NICU not on licence HSD/PHF/2019/0417; SCN covered under Paediatrics
Not Applicable
12DCritical Care Services - Paediatric Intensive Care / PICU
Out of scope: Dedicated PICU not on licence HSD/PHF/2019/0417; transfers routed to regional tertiary centre
Not Applicable
12ECritical Care Services - Cardiothoracic ICU
Out of scope: Cardiothoracic surgical services not provided or on licence HSD/PHF/2019/0417
Not Applicable
12FCritical Care Services - Burns Unit
Out of scope: Specialised burns care unit not on licence HSD/PHF/2019/0417
Not Applicable
13Labour Delivery Services
Licensed service: Labour Delivery Services
14 criteria
Partially met
14Emergency Medical and Trauma Services
Licensed service: Emergency Medical and Trauma Services
1 Core14 criteria
Not met

Procedural and support

7 of 11 in scope
15Dietary and Food Services
Licensed service: Dietary and Food Services
14 criteria
Fully met
16Central Sterile Supply Services (CSSD)
Licensed service: Central Sterile Supply Services (CSSD)
3 Core3 Safety18 criteria
Partially met
17APhysiotherapy Services
Licensed service: Physiotherapy Services
1 Core14 criteria
Not met
17BOccupational Therapy Services
Licensed service: Occupational Therapy Services
14 criteria
Not met
17CSpeech Language Therapy Services
Out of scope: Speech therapy offered via visiting sessional consultant; no in-house facility on licence
Not Applicable
17DClinical Psychology Services
Out of scope: Clinical psychology outpatient service not on licence HSD/PHF/2019/0417
Not Applicable
17EAudiology Services
Out of scope: Audiological diagnostics not on licence HSD/PHF/2019/0417
Not Applicable
17FPodiatry Services
Out of scope: Podiatry services not on licence HSD/PHF/2019/0417
Not Applicable
18Pharmacy Services
Licensed service: Pharmacy Services
4 Core3 Safety18 criteria
Partially met
19Diagnostic Imaging Services
Licensed service: Diagnostic Imaging Services
1 Core1 Safety16 criteria
Not met
20Pathology and Clinical Laboratory Services
Licensed service: Pathology and Clinical Laboratory Services
1 Core14 criteria
Not met

Allied health and support

5 of 16 in scope
21Linen and Laundry Services
Licensed service: Linen and Laundry Services
1 Core15 criteria
Not met
22Housekeeping and Cleaning Services
Licensed service: Housekeeping and Cleaning Services
15 criteria
Partially met
23AMortuary Services
Licensed service: Mortuary Services
1 Core15 criteria
Partially met
23BForensic Pathology and Medico-Legal Mortuary Services
Out of scope: Forensic medico-legal autopsies designated to Hospital Kajang (MOH facility)
Not Applicable
24General Administration and Support Services
Licensed service: General Administration and Support
14 criteria
Partially met
25Blood Transfusion Services
Licensed service: Blood Transfusion Services
6 Core14 criteria
Partially met
26Nuclear Medicine Services
Out of scope: Nuclear medicine and PET-CT services not on licence HSD/PHF/2019/0417
Not Applicable
27Radiotherapy and Oncology Daycare Services
Out of scope: Linear accelerator and radiotherapy not on licence HSD/PHF/2019/0417
Not Applicable
28Haemodialysis Services
Out of scope: Chronic haemodialysis unit outsourced and not on licence HSD/PHF/2019/0417
Not Applicable
29Assisted Reproductive Technology (ART) Services
Out of scope: IVF / ART services not provided or on licence HSD/PHF/2019/0417
Not Applicable
30Cellular Therapy and Bone Marrow Transplant Services
Out of scope: Cellular and transplant therapies not on licence HSD/PHF/2019/0417
Not Applicable
31Dental and Maxillofacial Surgery Services
Out of scope: Dental surgery clinic not on licence HSD/PHF/2019/0417
Not Applicable
32Hyperbaric Oxygen Therapy Services
Out of scope: Hyperbaric chamber not yet endorsed on licence HSD/PHF/2019/0417
Not Applicable
33Clinical Research and Trial Services
Out of scope: Dedicated Phase 1 clinical trial unit not on licence HSD/PHF/2019/0417
Not Applicable
34Medical Transportation and Inter-Facility Ambulance Services
Out of scope: Ambulance fleet outsourced to contracted provider
Not Applicable
35Information and Communication Technology (ICT) Services
Out of scope: ICT governance addressed under Standard 01 and 08; stand-alone standard not licensed separately
Not Applicable