Governance, Leadership and Direction
Core services · Licensed in-scope service
Criterion | Self-rating | Surveyor rating | Divergence | Evidence | Person in charge | Last updated |
|---|---|---|---|---|---|---|
1.1.1.1Core Standard Vision, Mission and Core Values | Fully met | Fully met | — | 2 docs | Pn. Rohani binti Ismail | 2026-01-15 |
1.1.2.1Core Standard Organisational and Committee Structure | Fully met | Fully met | — | 1 doc | Pn. Rohani binti Ismail | 2026-01-16 |
1.1.3.1Core Standard Statutory Licences and Compliance | Fully met | Fully met | — | 2 docs | Pn. Rohani binti Ismail | 2026-01-18 |
1.1.3.10 Information Technology Continuity and Cyber Resilience | Fully met | Partially met | 1 doc | En. Azman bin Yahya | 2026-01-20 | |
1.2.1.1 Human Resource Planning and Staff Establishment | Fully met | Fully met | — | 1 doc | Pn. Aishah Kamal | 2026-01-12 |
1.2.2.1Core StandardSafety Standard Credentialing and Privileging of Medical Practitioners | Fully met | Fully met | — | 1 doc | Dr. Azmi Razak | 2026-01-10 |
1.2.4.1 Staff Continuous Professional Development and Training | Fully met | Fully met | — | 1 doc | Pn. Aishah Kamal | 2026-01-14 |
1.2.7.1Core Standard Workforce Physical, Mental and Spiritual Wellbeing | Fully met | Not met | 1 doc | Pn. Aishah Kamal | 2026-01-14 | |
1.3.1 Quality Improvement and Patient Safety Programme | Fully met | — | — | None | Pn. Rohani binti Ismail | 2026-01-18 |
1.3.2 Risk Management and Clinical Governance Oversight | Fully met | — | — | None | Pn. Rohani binti Ismail | 2026-01-19 |
1.3.4 Incident Reporting and Significant Incident (SIQ) Investigation | Fully met | — | — | None | Pn. Rohani binti Ismail | 2026-01-22 |
1.4.1.4 Governance and Ethical Deployment of Digital and AI Tools | Fully met | — | — | None | En. Azman bin Yahya | 2026-01-25 |
01.1.1.11 Executive Governance Protocol 1.1 | Partially met | Fully met | None | Pn. Rohani binti Ismail | 2026-01-11 | |
01.1.2.12 Clinical Oversight Protocol 1.2 | Partially met | Fully met | None | Pn. Rohani binti Ismail | 2026-01-12 | |
01.1.3.13 Strategic Leadership Protocol 1.3 | Partially met | Fully met | None | Pn. Rohani binti Ismail | 2026-01-13 | |
01.1.4.14 Statutory Compliance Protocol 1.4 | Fully met | Partially met | None | Pn. Rohani binti Ismail | 2026-01-14 | |
01.2.1.15 Workforce Welfare Protocol 2.1 | Fully met | Partially met | None | Pn. Rohani binti Ismail | 2026-01-15 | |
01.2.2.16 Data Ethics Protocol 2.2 | Fully met | Partially met | None | Pn. Rohani binti Ismail | 2026-01-16 | |
01.2.3.17 Executive Governance Protocol 2.3 | Partially met | Fully met | None | Pn. Rohani binti Ismail | 2026-01-17 | |
01.2.4.18 Clinical Oversight Protocol 2.4 | Partially met | Fully met | None | Pn. Rohani binti Ismail | 2026-01-18 | |
01.3.1.19 Strategic Leadership Protocol 3.1 | Partially met | Fully met | None | Pn. Rohani binti Ismail | 2026-01-19 | |
01.3.2.20 Statutory Compliance Protocol 3.2 | Partially met | Fully met | None | Pn. Rohani binti Ismail | 2026-01-20 | |
01.3.3.21 Workforce Welfare Protocol 3.3 | Fully met | Fully met | — | None | Pn. Rohani binti Ismail | 2026-01-21 |
01.3.4.22 Data Ethics Protocol 3.4 | Partially met | Partially met | — | None | Pn. Rohani binti Ismail | 2026-01-22 |
01.4.1.23 Executive Governance Protocol 4.1 | Fully met | Fully met | — | None | Pn. Rohani binti Ismail | 2026-01-23 |
01.4.2.24 Clinical Oversight Protocol 4.2 | Fully met | Fully met | — | None | Pn. Rohani binti Ismail | 2026-01-24 |
01.4.3.25 Strategic Leadership Protocol 4.3 | Not met | Not met | — | None | Pn. Rohani binti Ismail | 2026-01-25 |