Survey Team Accreditation Recommendation & Gate
Deterministic MSQH 7th Edition Gate evaluation, Core and Safety criterion compliance, and Council recommendation docket.
Delayed Accreditation: 1 Core Criterion Non-Compliant
Core Criterion 1.2.7.1 (Workforce Physical, Mental and Spiritual Wellbeing) rated Not met — blocks 4-year award.
Mandatory pass rule: 100% required. Failing criterion: 1.2.7.1.
All 22 national patient safety criteria verified compliant with no unhandled breaches.
463 compliant, 46 non-compliant across 31 in-scope standards.
Survey Cycle Longitudinal Performance: 2022 vs 2026
Major enhancement in hand hygiene monitoring, SSI surveillance, and isolation room negative pressure controls.
Automated LASA drug double-checking and clinical pharmacist ward presence fully established.
Upgraded ventilator weaning protocol and central line infection bundle execution.
Consistently robust triage door-to-doctor times and red zone resuscitation equipment readiness.
Radiation safety compliance and PACS archival integrity maintained across all modalities.
Regression due to unaddressed workforce mental health surveillance and lack of approved policy on Core 1.2.7.1.