Reports

Mid Valley My day

A73

Centre ISEC Mid Valley

Last 12 months · 6 Oct 2025 – 5 Oct 2026

Element Evidence

266


Gov	Downtime, security and governance evidence	Access review signed this quarter	Not met	95	EV-89-z5pk	bffd0f25ef	UAR-0011
Gov	Downtime, security and governance evidence	Continuity exercise held in the last 6 months	Met	40	EV-99-z5pk	39445abc0e	DRL-0081
Gov	Usage adoption percentage from logs	Orders entered by the prescriber (CPOE)	Met	100	EV-103-z5pk	3deecd6812	ORD-100012; ORD-100013; ORD-100016; ORD-100106; ORD-100107
Gov	Usage adoption percentage from logs	Discharge summaries signed in the HIS	Met	100	EV-105-z5pk	169107f09d	EPI-2608-70205; EPI-2608-70975; EPI-2608-71151; EPI-2608-71327; EPI-2608-71349
Gov	Usage adoption percentage from logs	Patient portal self-service use	At risk	50	EV-106-z5pk	15fb9e953f	APT-18-1\|1; APT-31-1\|2; APT-44-1\|3; APT-5-1\|0
Stage 1-2	Ancillary systems and clinical data repository	Clinical data repository in use	Met	516	EV-101-z5pk	c5839c47a7	96:7:MLV-MV-713186-3@15/01/2024 06:00; APT-18-1\|1; APT-31-1\|2; APT-44-1\|3; APT-5-1\|0
Stage 3	Nursing documentation, eMAR, CDS alerts	eMAR doses scanned	Not met	0	EV-102-z5pk	13d8473d59	96:7:MLV-MV-713186-3@15/01/2024 06:00
Stage 4	CPOE with decision support	Orders entered by the prescriber (CPOE)	Met	100	EV-103-z5pk	3deecd6812	ORD-100012; ORD-100013; ORD-100016; ORD-100106; ORD-100107
Stage 5	Closed-loop medication / barcode scanning	eMAR doses scanned	Not met	0	EV-102-z5pk	13d8473d59	96:7:MLV-MV-713186-3@15/01/2024 06:00
Stage 5	Closed-loop medication / barcode scanning	Closed-loop medication	At risk	88.7	EV-104-z5pk	752eeec66e	ORD-101617; ORD-101618; ORD-101690; ORD-101908; ORD-101909
Stage 6	Structured documentation, e-discharge, order-set use	Discharge summaries signed in the HIS	Met	100	EV-105-z5pk	169107f09d	EPI-2608-70205; EPI-2608-70975; EPI-2608-71151; EPI-2608-71327; EPI-2608-71349
Stage 7	Data analytics, HIE, patient portal use	Patient portal self-service use	At risk	50	EV-106-z5pk	15fb9e953f	APT-18-1\|1; APT-31-1\|2; APT-44-1\|3; APT-5-1\|0
4	Context and interested parties	Context issues reviewed	Not met	85.7	EV-43-z5pk	11f514ab0d	CTX-001; CTX-002; CTX-003; CTX-004; CTX-005
4	Context and interested parties	Interested parties listed	Met	9	EV-44-z5pk	d6b724d089	IPA-001; IPA-002; IPA-003; IPA-004; IPA-005
6.1.2	Environmental aspects and impacts	Environmental aspects register kept	Met	9	EV-75-z5pk	c59c474a0f	EA1; EA2; EA3; EA4; EA5
6.1.2	Environmental aspects and impacts	Significant aspects reviewed	Not met	0	EV-76-z5pk	8f649f1569	EA1; EA2; EA4
6.1.3	Compliance obligations	Legal requirements evaluated	Not met	0	EV-64-z5pk	d60d1786f4	B1; B11; B14; B15; B16
6.1.3	Compliance obligations	No legal requirement evaluated as not compliant	Met	0	EV-65-z5pk	4f53cda18c	—
6.2	Environmental objectives	Objectives on track	Not met	45.5	EV-45-z5pk	82c2d77b9a	OBJ-001; OBJ-002; OBJ-003; OBJ-004; OBJ-005
7.2	Competence and awareness	Mandatory training current	At risk	82.5	EV-50-z5pk	d519cb11c1	HR-0; HR-1; HR-10; HR-100; HR-101
8.1	Waste segregation, scheduled waste control	Clinical waste consignments received (e-SWIS)	Not met	62.5	EV-74-z5pk	29db807fc9	WL-2023-10-isec-kl; WL-2023-10-isec-pg; WL-2023-11-isec-kl; WL-2023-11-isec-mv; WL-2023-11-isec-pg
8.1	Supplier environmental control	Critical outsourced services evaluated on plan	Not met	86.7	EV-39-z5pk	792e47d095	SUP-154; SUP-155; SUP-156; SUP-157; SUP-158
8.2	Emergency preparedness (spill, fire)	No emergency drill overdue	Met	0	EV-66-z5pk	4f53cda18c	—
9.1.1	Monitoring: energy, water, waste, GHG	Meter readings logged with meter numbers	Not met	0	EV-77-z5pk	77be22bf3b	isec-kl\|elec; isec-kl\|fuel; isec-kl\|water; isec-mv\|elec; isec-mv\|fuel
9.1.2	Compliance evaluation	Legal requirements evaluated	Not met	0	EV-64-z5pk	d60d1786f4	B1; B11; B14; B15; B16
9.2	Internal audit	Internal audit held this quarter	Met	25	EV-46-z5pk	2709ad504e	IA-009
9.2	Internal audit	No audit finding overdue	Not met	1	EV-47-z5pk	5b893f2935	IAF-004
9.3	Management review	Management review approved in the last 12 months	Met	168	EV-48-z5pk	03621322a7	MR-001
4	Context, interested parties, BCMS scope	Context issues reviewed	Not met	85.7	EV-43-z5pk	11f514ab0d	CTX-001; CTX-002; CTX-003; CTX-004; CTX-005
4	Context, interested parties, BCMS scope	Interested parties listed	Met	9	EV-44-z5pk	d6b724d089	IPA-001; IPA-002; IPA-003; IPA-004; IPA-005
6.2	Business continuity objectives	Objectives on track	Not met	45.5	EV-45-z5pk	82c2d77b9a	OBJ-001; OBJ-002; OBJ-003; OBJ-004; OBJ-005
6.2	Business continuity objectives	Recovery objectives met when tested	Not met	40	EV-97-z5pk	2496f15638	BCP-bill; BCP-cssd; BCP-emr; BCP-imaging; BCP-ivi
7.2	Competence and awareness	Mandatory training current	At risk	82.5	EV-50-z5pk	d519cb11c1	HR-0; HR-1; HR-10; HR-100; HR-101
8.2	Supplier dependency review	IT vendor reviews not overdue	Not met	2	EV-92-z5pk	5c97b2015a	ITV-0023; ITV-0025
8.2.2	Business impact analysis	Business impact analysis: RTO and RPO set per process	Met	100	EV-98-z5pk	97ec6dd2cd	BIA-bill; BIA-cssd; BIA-emr; BIA-imaging; BIA-ivi
8.2.3	Risk assessment	Risk register kept with owners	Met	14	EV-26-z5pk	0d6c73d258	RSK-001; RSK-002; RSK-003; RSK-004; RSK-005
8.3	Continuity strategies and solutions	Recovery objectives met when tested	Not met	40	EV-97-z5pk	2496f15638	BCP-bill; BCP-cssd; BCP-emr; BCP-imaging; BCP-ivi
8.4	Business continuity plans and procedures	Recovery objectives met when tested	Not met	40	EV-97-z5pk	2496f15638	BCP-bill; BCP-cssd; BCP-emr; BCP-imaging; BCP-ivi
8.5	Exercise and testing programme	Continuity exercise held in the last 6 months	Met	40	EV-99-z5pk	39445abc0e	DRL-0081
8.5	Exercise and testing programme	No continuity exercise overdue	Not met	1	EV-100-z5pk	57e0313445	DUE-cssd
9.2	Internal audit	Internal audit held this quarter	Met	25	EV-46-z5pk	2709ad504e	IA-009
9.2	Internal audit	No audit finding overdue	Not met	1	EV-47-z5pk	5b893f2935	IAF-004
9.3	Management review	Management review approved in the last 12 months	Met	168	EV-48-z5pk	03621322a7	MR-001
4	Context, workers needs, OSH scope	Context issues reviewed	Not met	85.7	EV-43-z5pk	11f514ab0d	CTX-001; CTX-002; CTX-003; CTX-004; CTX-005
4	Context, workers needs, OSH scope	Interested parties listed	Met	9	EV-44-z5pk	d6b724d089	IPA-001; IPA-002; IPA-003; IPA-004; IPA-005
5.4	Worker consultation and OSH committee	OSH committee meets to schedule	Met	87.5	EV-80-z5pk	f235bdc3b0	OSH-001; OSH-002; OSH-003; OSH-004; OSH-005
6.1.2	Hazard identification and risk assessment (HIRARC)	HIRARC register kept	Met	9	EV-81-z5pk	7ed5b80d77	HIR-001; HIR-002; HIR-003; HIR-004; HIR-005
6.1.3	Legal and other requirements	Legal requirements evaluated	Not met	0	EV-64-z5pk	d60d1786f4	B1; B11; B14; B15; B16
6.1.3	Legal and other requirements	No legal requirement evaluated as not compliant	Met	0	EV-65-z5pk	4f53cda18c	—
7.2	OSH competence and training	Mandatory training current	At risk	82.5	EV-50-z5pk	d519cb11c1	HR-0; HR-1; HR-10; HR-100; HR-101
7.2	OSH competence and training	Training effectiveness checked when due	Met	0	EV-53-z5pk	4f53cda18c	—
8.1	Operational control, permit-to-work, PPE	Permit-to-work used	Met	4	EV-82-z5pk	4731b6d7f7	PTW-001; PTW-002; PTW-003; PTW-004
8.1	Operational control, permit-to-work, PPE	PPE issued and not due for replacement	At risk	75	EV-83-z5pk	11b7fcafda	PPE-001; PPE-002; PPE-003; PPE-004
8.1	Occupational health surveillance and vaccination	Staff vaccination complete	At risk	82.5	EV-31-z5pk	ceb1a6466a	VAX-0; VAX-1; VAX-10; VAX-100; VAX-101
8.1	Occupational health surveillance and vaccination	Needle-stick injuries followed up	Met	—	EV-32-z5pk	4f53cda18c	—
8.1	Occupational health surveillance and vaccination	Health surveillance not overdue	Not met	4	EV-33-z5pk	aa2069dab2	f51-2; f61-2; f65-2; f9-2
8.2	Emergency preparedness and drills	No emergency drill overdue	Met	0	EV-66-z5pk	4f53cda18c	—
9.1	Monitoring: incidents, lost-time, exposure	Lost-time injury log kept	Met	4	EV-84-z5pk	d765abd81d	LTI-001; LTI-002; LTI-003; LTI-004
9.1.2	Compliance evaluation (DOSH CF, statutory tests)	No statutory plant certificate expired (DOSH)	Met	0	EV-61-z5pk	4f53cda18c	—
9.1.2	Compliance evaluation (DOSH CF, statutory tests)	Legal requirements evaluated	Not met	0	EV-64-z5pk	d60d1786f4	B1; B11; B14; B15; B16
9.1.2	Compliance evaluation (DOSH CF, statutory tests)	Inspection certificates carry their number	Not met	12	EV-68-z5pk	9fcdfd6194	airrec\|isec-kl; airrec\|isec-mv; airrec\|isec-pg; autoclave\|isec-kl; autoclave\|isec-mv
9.2	Internal audit	Internal audit held this quarter	Met	25	EV-46-z5pk	2709ad504e	IA-009
9.2	Internal audit	No audit finding overdue	Not met	1	EV-47-z5pk	5b893f2935	IAF-004
9.3	Management review	Management review approved in the last 12 months	Met	168	EV-48-z5pk	03621322a7	MR-001
10.2	Incident investigation and corrective action	No incident past its due date	Not met	1	EV-22-z5pk	55b8a53e0c	INC-2610-003
10.2	Incident investigation and corrective action	No overdue corrective action	Met	100	EV-24-z5pk	d49821bdad	CAPA-2024-01
10.2	Incident investigation and corrective action	Finished actions checked for effect	Met	100	EV-25-z5pk	c5008a2037	CAPA-2024-01
4	Context and EnMS scope	Context issues reviewed	Not met	85.7	EV-43-z5pk	11f514ab0d	CTX-001; CTX-002; CTX-003; CTX-004; CTX-005
4	Context and EnMS scope	Interested parties listed	Met	9	EV-44-z5pk	d6b724d089	IPA-001; IPA-002; IPA-003; IPA-004; IPA-005
6.2	Energy objectives and action plans	Objectives on track	Not met	45.5	EV-45-z5pk	82c2d77b9a	OBJ-001; OBJ-002; OBJ-003; OBJ-004; OBJ-005
6.3	Energy review, significant energy uses	Energy indicators within target	Not met	0	EV-78-z5pk	15e601e896	ghgv; kwhp; kwhv; watv
6.3	Energy review, significant energy uses	Energy baseline and indicators defined	Met	4	EV-79-z5pk	7c35b24b02	ghgv; kwhp; kwhv; watv
6.4	Energy performance indicators and baseline	Energy indicators within target	Not met	0	EV-78-z5pk	15e601e896	ghgv; kwhp; kwhv; watv
6.4	Energy performance indicators and baseline	Energy baseline and indicators defined	Met	4	EV-79-z5pk	7c35b24b02	ghgv; kwhp; kwhv; watv
7.2	Competence and awareness	Mandatory training current	At risk	82.5	EV-50-z5pk	d519cb11c1	HR-0; HR-1; HR-10; HR-100; HR-101
8.1	Operational control of equipment (HVAC, OT)	No equipment calibration expired	Not met	2	EV-62-z5pk	84a257455a	CAL\|EQ-005; CAL\|EQ-011
8.1	Operational control of equipment (HVAC, OT)	No open temperature or humidity excursion	Met	0	EV-70-z5pk	4f53cda18c	—
8.2	Design/procurement with energy performance	Critical outsourced services evaluated on plan	Not met	86.7	EV-39-z5pk	792e47d095	SUP-154; SUP-155; SUP-156; SUP-157; SUP-158
9.1	Metering, monitoring, measurement	Meter readings logged with meter numbers	Not met	0	EV-77-z5pk	77be22bf3b	isec-kl\|elec; isec-kl\|fuel; isec-kl\|water; isec-mv\|elec; isec-mv\|fuel
9.2	Internal audit	Internal audit held this quarter	Met	25	EV-46-z5pk	2709ad504e	IA-009
9.2	Internal audit	No audit finding overdue	Not met	1	EV-47-z5pk	5b893f2935	IAF-004
9.3	Management review	Management review approved in the last 12 months	Met	168	EV-48-z5pk	03621322a7	MR-001
10.2	Nonconformity and continual improvement	No overdue corrective action	Met	100	EV-24-z5pk	d49821bdad	CAPA-2024-01
10.2	Nonconformity and continual improvement	Finished actions checked for effect	Met	100	EV-25-z5pk	c5008a2037	CAPA-2024-01
4	Context, interested parties, QMS scope	Context issues reviewed	Not met	85.7	EV-43-z5pk	11f514ab0d	CTX-001; CTX-002; CTX-003; CTX-004; CTX-005
4	Context, interested parties, QMS scope	Interested parties listed	Met	9	EV-44-z5pk	d6b724d089	IPA-001; IPA-002; IPA-003; IPA-004; IPA-005
5	Leadership, quality policy, roles	A published policy is on file	Met	5	EV-38-z5pk	ceca603b53	DOC-003; DOC-006; DOC-009; DOC-012; DOC-015
5	Leadership, quality policy, roles	Job descriptions current and acknowledged	At risk	84.2	EV-41-z5pk	74d1d086cd	JD-Admin; JD-Anaesthesiologist; JD-Anaesthetic Nurse; JD-Checklist Coordinator; JD-Circulating Nurse
5	Leadership, quality policy, roles	Organisation chart published	Met	2	EV-42-z5pk	cf478ec5a1	ORG-v1; ORG-v2
6.1	Risks and opportunities	Risk register kept with owners	Met	14	EV-26-z5pk	0d6c73d258	RSK-001; RSK-002; RSK-003; RSK-004; RSK-005
6.1	Risks and opportunities	Opportunities register kept	Met	5	EV-27-z5pk	bca7f0bfdc	OPP-001; OPP-002; OPP-003; OPP-004; OPP-005
6.2	Quality objectives and plans	Objectives on track	Not met	45.5	EV-45-z5pk	82c2d77b9a	OBJ-001; OBJ-002; OBJ-003; OBJ-004; OBJ-005
7.2	Competence and awareness records	Mandatory training current	At risk	82.5	EV-50-z5pk	d519cb11c1	HR-0; HR-1; HR-10; HR-100; HR-101
7.2	Competence and awareness records	Competencies signed off	Met	93.6	EV-52-z5pk	84065f7abf	c10-2; c103-0; c103-1; c104-4; c104-5
7.2	Competence and awareness records	Training effectiveness checked when due	Met	0	EV-53-z5pk	4f53cda18c	—
7.5	Documented information control	Policies and SOPs published and in review date	At risk	85	EV-36-z5pk	8fc950a366	DOC-001; DOC-002; DOC-003; DOC-004; DOC-005
7.5	Documented information control	Documents read and signed by 80% of their audience	At risk	60	EV-37-z5pk	8ac0c51905	DOC-001; DOC-002; DOC-003; DOC-004; DOC-005
8.4	Supplier evaluation and control	Critical outsourced services evaluated on plan	Not met	86.7	EV-39-z5pk	792e47d095	SUP-154; SUP-155; SUP-156; SUP-157; SUP-158
8.4	Supplier evaluation and control	Outsourced-service certificates complete	Not met	42.1	EV-40-z5pk	9f79c5a051	SUP-154; SUP-155; SUP-156; SUP-157; SUP-158
8.5	Service delivery, traceability, release	IOL lot recorded at Sign-Out	Not met	0	EV-5-z5pk	bb24c5ec70	WHO-2023-12; WHO-2024-01
9.1	Customer satisfaction and monitoring	Patient review scores at target	At risk	66.7	EV-49-z5pk	b24dd72568	REV-001; REV-002; REV-003; REV-004; REV-005
9.2	Internal audit programme and results	Internal audit held this quarter	Met	25	EV-46-z5pk	2709ad504e	IA-009
9.2	Internal audit programme and results	No audit finding overdue	Not met	1	EV-47-z5pk	5b893f2935	IAF-004
9.3	Management review inputs/outputs	Management review approved in the last 12 months	Met	168	EV-48-z5pk	03621322a7	MR-001
10.2	Nonconformity and corrective action	No incident past its due date	Not met	1	EV-22-z5pk	55b8a53e0c	INC-2610-003
10.2	Nonconformity and corrective action	No overdue corrective action	Met	100	EV-24-z5pk	d49821bdad	CAPA-2024-01
10.2	Nonconformity and corrective action	Finished actions checked for effect	Met	100	EV-25-z5pk	c5008a2037	CAPA-2024-01
4-10	Risk assessment, SoA, internal audit, management review	Context issues reviewed	Not met	85.7	EV-43-z5pk	11f514ab0d	CTX-001; CTX-002; CTX-003; CTX-004; CTX-005
4-10	Risk assessment, SoA, internal audit, management review	Internal audit held this quarter	Met	25	EV-46-z5pk	2709ad504e	IA-009
4-10	Risk assessment, SoA, internal audit, management review	Management review approved in the last 12 months	Met	168	EV-48-z5pk	03621322a7	MR-001
4-10	Risk assessment, SoA, internal audit, management review	Applicable controls implemented (SoA)	Not met	58.1	EV-96-z5pk	9624b1fa64	5.1; 5.10; 5.11; 5.12; 5.13
A.5	Incident management, legal, privacy (PDPA)	Data protection officers appointed	Met	100	EV-86-z5pk	0d8733c413	DPO-001; DPO-002; DPO-003; DPO-004; DPO-005
A.5	Incident management, legal, privacy (PDPA)	Data processing agreements signed	Not met	1	EV-93-z5pk	1fee856c1a	ITV-0023
A.5	Incident management, legal, privacy (PDPA)	No high-severity IT incident open	Not met	1	EV-94-z5pk	4e7f9f4cfe	ITI-0054
A.5	Business continuity for ICT	Recovery objectives met when tested	Not met	40	EV-97-z5pk	2496f15638	BCP-bill; BCP-cssd; BCP-emr; BCP-imaging; BCP-ivi
A.5 Organisational	Policies, roles, asset inventory, supplier security	Documents read and signed by 80% of their audience	At risk	60	EV-37-z5pk	8ac0c51905	DOC-001; DOC-002; DOC-003; DOC-004; DOC-005
A.5 Organisational	Policies, roles, asset inventory, supplier security	IT asset register kept	Met	25	EV-90-z5pk	56a44ab0e0	IF-CCOW; IF-DCM; IF-DIR; IF-KDC; IF-LDAP
A.5 Organisational	Policies, roles, asset inventory, supplier security	IT vendor reviews not overdue	Not met	2	EV-92-z5pk	5c97b2015a	ITV-0023; ITV-0025
A.6 People	Screening, terms, awareness training, leaver process	Leavers closed on their last day	Not met	3	EV-95-z5pk	15067dfbbc	USR-1087; USR-1164; USR-1190
A.7 Physical	Secure areas, equipment siting, clear desk	Physical security checks not overdue	Met	0	EV-69-z5pk	4f53cda18c	—
A.8	User access, privileged access, access review	Access review signed this quarter	Not met	95	EV-89-z5pk	bffd0f25ef	UAR-0011
A.8	Logging, monitoring, audit trail	Audit trail kept	Not met	0	EV-85-z5pk	4f53cda18c	—
A.8	Backup and restore testing	Backup restore test passed this quarter	Met	17	EV-87-z5pk	8e98040492	BRT-0301
A.8	Backup and restore testing	No backup test overdue	Not met	1	EV-88-z5pk	c83dcd627a	DUE-Imagingarchive
A.8	Vulnerability, patching, change management	No asset with patching overdue	Not met	4	EV-91-z5pk	05675d4577	ITA-0104; ITA-0106; ITA-0110; ITA-0111
A.8	Cryptography, network, secure development	No HIS source	Not met	—	—		—
ACC	Access, triage criteria, discharge and referral	No HIS source	Not met	—	—		—
ASC	Assessment, anaesthesia/sedation records, surgical record, pain	WHO Sign-In signed (anaesthesia check, consent)	Not met	80.8	EV-7-z5pk	ec9ecd012f	OT-15586; OT-15587; OT-15588; OT-15589; OT-15590
ASC	Assessment, anaesthesia/sedation records, surgical record, pain	WHO Sign-Out signed	Not met	80.8	EV-8-z5pk	636b1145c4	OT-15586; OT-15587; OT-15588; OT-15589; OT-15590
ASC	Postoperative outcome follow-up by surgeon	Surgeon outcome review signed	Not met	0	EV-9-z5pk	cab94db898	SUR-T.S.L.; SUR-C.J.B.; SUR-C.S.W.; SUR-F.S.K.; SUR-H.W.O.
ASC	Postoperative outcome follow-up by surgeon	Flagged cases peer reviewed	At risk	88.9	EV-10-z5pk	49265feebc	SUR-T.S.L.; SUR-A.T.; SUR-A.A.J.S.; SUR-A.R.; SUR-B.J.
FMS	Equipment PPM, calibration, inventory, recalls	No equipment calibration expired	Not met	2	EV-62-z5pk	84a257455a	CAL\|EQ-005; CAL\|EQ-011
FMS	Fire, evacuation, utilities, hazardous materials, waste	No emergency drill overdue	Met	0	EV-66-z5pk	4f53cda18c	—
FMS	Fire, evacuation, utilities, hazardous materials, waste	No safety inspection overdue	Not met	1	EV-67-z5pk	c39e90fc41	ext\|isec-mv
FMS	Fire, evacuation, utilities, hazardous materials, waste	Clinical waste consignments received (e-SWIS)	Not met	62.5	EV-74-z5pk	29db807fc9	WL-2023-10-isec-kl; WL-2023-10-isec-pg; WL-2023-11-isec-kl; WL-2023-11-isec-mv; WL-2023-11-isec-pg
FMS	Temperature/humidity and laser safety	No open temperature or humidity excursion	Met	0	EV-70-z5pk	4f53cda18c	—
FMS	Temperature/humidity and laser safety	Environment readings logged today	Not met	0	EV-71-z5pk	a7a3d0ccdf	cssd\|isec-kl; cssd\|isec-mv; cssd\|isec-pg; frivi\|isec-kl; frivi\|isec-mv
FMS	Temperature/humidity and laser safety	Laser safety check done before use	Met	0	EV-72-z5pk	4f53cda18c	—
FMS	Temperature/humidity and laser safety	Every laser checked	Not met	0	EV-73-z5pk	1272fec6d1	LZ-1; LZ-2; LZ-3; LZ-4; LZ-5
GLD	Governance, leadership, committees, policies, ethics	Committee met within the last quarter	Met	28	EV-34-z5pk	9fd1904502	CMM-004
GLD	Governance, leadership, committees, policies, ethics	Committee decisions not overdue	Not met	1	EV-35-z5pk	9929629e07	DCL-004
GLD	Governance, leadership, committees, policies, ethics	Policies and SOPs published and in review date	At risk	85	EV-36-z5pk	8fc950a366	DOC-001; DOC-002; DOC-003; DOC-004; DOC-005
GLD	Contracted services and supplier evaluation	Critical outsourced services evaluated on plan	Not met	86.7	EV-39-z5pk	792e47d095	SUP-154; SUP-155; SUP-156; SUP-157; SUP-158
GLD	Contracted services and supplier evaluation	Outsourced-service certificates complete	Not met	42.1	EV-40-z5pk	9f79c5a051	SUP-154; SUP-155; SUP-156; SUP-157; SUP-158
IPSG.1	Two patient identifiers used before care	Wristband scan or IC check before the operation	Not met	80.8	EV-1-z5pk	171b6fae19	OT-15586; OT-15587; OT-15588; OT-15589; OT-15590
IPSG.2	Verbal/critical result communication read-back	Verbal orders read back (time logged)	Not met	—	EV-2-z5pk	4f53cda18c	—
IPSG.3	High-alert medication handling and double-check	No HIS source	Not met	—	—		—
IPSG.4	Safe surgery: site mark, time-out, correct procedure	WHO time-out signed	Not met	80.8	EV-3-z5pk	4a9d9c8d87	OT-15586; OT-15587; OT-15588; OT-15589; OT-15590
IPSG.4	Safe surgery: site mark, time-out, correct procedure	Operation site marked and confirmed	Not met	0	EV-4-z5pk	7f61e74ee4	WHO-2023-12; WHO-2024-01
IPSG.5	Hand hygiene compliance audits	Hand hygiene compliance	At risk	89.4	EV-6-z5pk	904d6848c5	HH-2024-01-CSSD; HH-2024-01-Day Care Unit; HH-2024-01-Eye casualty; HH-2024-01-Eye clinic; HH-2024-01-Operating theatre
IPSG.6	Fall-risk screening and prevention	No HIS source	Not met	—	—		—
MMU	Prescribing, dispensing, administration, storage, expiry	Antimicrobial lines reviewed by a pharmacist	Not met	0	EV-14-z5pk	c45c58af96	AMS-MV-ORD-2609-21003; AMS-MV-ORD-2609-21004; AMS-MV-ORD-2609-21009; AMS-MV-ORD-2609-21010; AMS-MV-ORD-2609-21017
MMU	Medication errors, LASA, controlled-drug reconciliation	Dangerous-drug count signed daily	Not met	0	EV-15-z5pk	018aea004d	DD-2024-01-09; DD-2024-01-10; DD-2024-01-11; DD-2024-01-12; DD-2024-01-13
MMU	Medication errors, LASA, controlled-drug reconciliation	Dangerous-drug variances reconciled	Met	0	EV-16-z5pk	4f53cda18c	—
MMU	Medication errors, LASA, controlled-drug reconciliation	LASA list kept (active pairs)	Met	8	EV-17-z5pk	4e460f3f09	LASA-S01; LASA-S02; LASA-S03; LASA-S04; LASA-S05
MMU	Medication errors, LASA, controlled-drug reconciliation	Medication errors classified (NCC MERP)	Met	100	EV-18-z5pk	601b1097fb	MER-2607-0001; MER-2607-0002; MER-2607-0003; MER-2607-0004; MER-2607-0005
MOI	Record content, authentication, retention, PDPA, downtime	Audit trail kept	Not met	0	EV-85-z5pk	4f53cda18c	—
MOI	Record content, authentication, retention, PDPA, downtime	Data protection officers appointed	Met	100	EV-86-z5pk	0d8733c413	DPO-001; DPO-002; DPO-003; DPO-004; DPO-005
MOI	Record content, authentication, retention, PDPA, downtime	Continuity exercise held in the last 6 months	Met	40	EV-99-z5pk	39445abc0e	DRL-0081
MOI	Information security and backup	Backup restore test passed this quarter	Met	17	EV-87-z5pk	8e98040492	BRT-0301
MOI	Information security and backup	Access review signed this quarter	Not met	95	EV-89-z5pk	bffd0f25ef	UAR-0011
PCC	Patient rights, informed consent, education, complaints	Patient rights acknowledged in the last 90 days	Not met	0	EV-11-z5pk	4f53cda18c	—
PCC	Patient rights, informed consent, education, complaints	Patient education recorded in the last 90 days	Not met	0	EV-12-z5pk	4f53cda18c	—
PCC	Patient rights, informed consent, education, complaints	Complaints answered within their due date	Met	0	EV-13-z5pk	4f53cda18c	—
PCI	Infection surveillance, sharps, sterilisation, reprocessing	Sharps audits done to schedule	At risk	50	EV-29-z5pk	ba9a34e3da	SHP-001; SHP-002; SHP-003; SHP-004
PCI	Infection surveillance, sharps, sterilisation, reprocessing	IPC cases logged and followed up	Met	0	EV-30-z5pk	4f53cda18c	—
PCI	Staff vaccination, needle-stick follow-up	Staff vaccination complete	At risk	82.5	EV-31-z5pk	ceb1a6466a	VAX-0; VAX-1; VAX-10; VAX-100; VAX-101
PCI	Staff vaccination, needle-stick follow-up	Needle-stick injuries followed up	Met	—	EV-32-z5pk	4f53cda18c	—
QPS	Quality indicators with data validation and trend	Indicators meeting their target	At risk	60	EV-20-z5pk	1885d1523c	IND-bi; IND-cancel; IND-endo; IND-endoivi; IND-hh
QPS	Quality indicators with data validation and trend	Indicator data validated this month	Not met	0	EV-21-z5pk	dc33db0b27	IND-bi; IND-cancel; IND-endo; IND-endoivi; IND-hh
QPS	Incident, near miss, sentinel event, RCA, CAPA	No incident past its due date	Not met	1	EV-22-z5pk	55b8a53e0c	INC-2610-003
QPS	Incident, near miss, sentinel event, RCA, CAPA	Sentinel event RCA within 45 days	Met	0	EV-23-z5pk	4f53cda18c	—
QPS	Incident, near miss, sentinel event, RCA, CAPA	No overdue corrective action	Met	100	EV-24-z5pk	d49821bdad	CAPA-2024-01
QPS	Risk register and proactive risk assessment	Risk register kept with owners	Met	14	EV-26-z5pk	0d6c73d258	RSK-001; RSK-002; RSK-003; RSK-004; RSK-005
SQE	Credentialing, privileging, licences, APC, CPD	Every registered practitioner holds a current APC	Met	100	EV-54-z5pk	7e3e7eb905	HR-10; HR-100; HR-101; HR-103; HR-104
SQE	Credentialing, privileging, licences, APC, CPD	CPD points met	Met	91.4	EV-55-z5pk	58319c21f7	HR-10; HR-100; HR-101; HR-103; HR-104
SQE	Credentialing, privileging, licences, APC, CPD	Privileges current for every procedure	Not met	91	EV-56-z5pk	f8db5d5d27	p0-0; p0-1; p0-2; p0-3; p0-4
SQE	Credentialing, privileging, licences, APC, CPD	Locum and visiting files complete	Not met	25	EV-57-z5pk	e7544d9135	f-2292999; f-2293551; f-2293589; f-2293785
SQE	Orientation, competency, job descriptions, appraisal	Job descriptions current and acknowledged	At risk	84.2	EV-41-z5pk	74d1d086cd	JD-Admin; JD-Anaesthesiologist; JD-Anaesthetic Nurse; JD-Checklist Coordinator; JD-Circulating Nurse
SQE	Orientation, competency, job descriptions, appraisal	Mandatory training current	At risk	82.5	EV-50-z5pk	d519cb11c1	HR-0; HR-1; HR-10; HR-100; HR-101
SQE	Orientation, competency, job descriptions, appraisal	Competencies signed off	Met	93.6	EV-52-z5pk	84065f7abf	c10-2; c103-0; c103-1; c104-4; c104-5
Care	Pre-op assessment, biometry, IOL selection record	Cataract registry: post-op VA recorded	Not met	—	EV-112-z5pk	4f53cda18c	—
Care	Informed consent specific to cataract and IOL	WHO Sign-In signed (anaesthesia check, consent)	Not met	80.8	EV-7-z5pk	ec9ecd012f	OT-15586; OT-15587; OT-15588; OT-15589; OT-15590
Care	Safe-surgery: site mark, wrong-eye gate, IOL check	WHO time-out signed	Not met	80.8	EV-3-z5pk	4a9d9c8d87	OT-15586; OT-15587; OT-15588; OT-15589; OT-15590
Care	Safe-surgery: site mark, wrong-eye gate, IOL check	Operation site marked and confirmed	Not met	0	EV-4-z5pk	7f61e74ee4	WHO-2023-12; WHO-2024-01
Care	Safe-surgery: site mark, wrong-eye gate, IOL check	IOL lot recorded at Sign-Out	Not met	0	EV-5-z5pk	bb24c5ec70	WHO-2023-12; WHO-2024-01
Care	Post-op follow-up schedule and adherence	Cataract follow-up attended	Not met	—	EV-113-z5pk	4f53cda18c	—
Outcome	Clinical outcome measures (VA, PCR, endophthalmitis)	PCR rate within target	Met	100	EV-109-z5pk	68198c1429	IND-pcr
Outcome	Clinical outcome measures (VA, PCR, endophthalmitis)	Endophthalmitis rate within target	Met	100	EV-110-z5pk	21ebae95eb	IND-endo
Outcome	Clinical outcome measures (VA, PCR, endophthalmitis)	Post-op VA 6/12 or better at target	Met	100	EV-111-z5pk	ae001555c1	IND-va
Outcome	Clinical outcome measures (VA, PCR, endophthalmitis)	Cataract registry: post-op VA recorded	Not met	—	EV-112-z5pk	4f53cda18c	—
Outcome	Patient-reported outcome / satisfaction by program	Patient-reported outcome captured	Not met	—	EV-114-z5pk	4f53cda18c	—
Patient	Education and self-management materials	Patient education recorded in the last 90 days	Not met	0	EV-12-z5pk	4f53cda18c	—
Program	Defined care pathway, clinical practice guideline	Cataract pathway documents published	Met	2	EV-107-z5pk	6eaafe52d4	DOC-004; DOC-005
Program	Program leader, multidisciplinary team, scope	Organisation chart published	Met	2	EV-42-z5pk	cf478ec5a1	ORG-v1; ORG-v2
Program	Program leader, multidisciplinary team, scope	Cataract programme team meets	Not met	0	EV-108-z5pk	4f53cda18c	—
QI	Program indicators, data validation, improvement	Indicators meeting their target	At risk	60	EV-20-z5pk	1885d1523c	IND-bi; IND-cancel; IND-endo; IND-endoivi; IND-hh
QI	Program indicators, data validation, improvement	Indicator data validated this month	Not met	0	EV-21-z5pk	dc33db0b27	IND-bi; IND-cancel; IND-endo; IND-endoivi; IND-hh
Staff	Surgeon privileging for cataract and phaco volume	Surgeon outcome review signed	Not met	0	EV-9-z5pk	cab94db898	SUR-T.S.L.; SUR-C.J.B.; SUR-C.S.W.; SUR-F.S.K.; SUR-H.W.O.
Staff	Surgeon privileging for cataract and phaco volume	Privileges current for every procedure	Not met	91	EV-56-z5pk	f8db5d5d27	p0-0; p0-1; p0-2; p0-3; p0-4
Act 586 s.12	Licence displayed, scope matches services, renewed	Centre licence number on file	Not met	0	EV-59-z5pk	24e0cf2b69	B11\|bangsar-south; B11\|isec-kl; B11\|isec-mv; B11\|isec-pg; B15\|bangsar-south
Act 586 s.12	Licence displayed, scope matches services, renewed	No centre licence expired	Met	0	EV-60-z5pk	4f53cda18c	—
Reg: anaesthesia	GA/sedation safeguards and emergency equipment	WHO Sign-In signed (anaesthesia check, consent)	Not met	80.8	EV-7-z5pk	ec9ecd012f	OT-15586; OT-15587; OT-15588; OT-15589; OT-15590
Reg: complaint	Complaints procedure and patient information	Complaints answered within their due date	Met	0	EV-13-z5pk	4f53cda18c	—
Reg: drugs	Poisons and dangerous-drug storage and registers	Dangerous-drug count signed daily	Not met	0	EV-15-z5pk	018aea004d	DD-2024-01-09; DD-2024-01-10; DD-2024-01-11; DD-2024-01-12; DD-2024-01-13
Reg: drugs	Poisons and dangerous-drug storage and registers	Dangerous-drug variances reconciled	Met	0	EV-16-z5pk	4f53cda18c	—
Reg: equipment	Equipment maintained and records kept	No statutory plant certificate expired (DOSH)	Met	0	EV-61-z5pk	4f53cda18c	—
Reg: equipment	Equipment maintained and records kept	No equipment calibration expired	Not met	2	EV-62-z5pk	84a257455a	CAL\|EQ-005; CAL\|EQ-011
Reg: laser/radiation	Laser and any ionising equipment safety	Laser safety check done before use	Met	0	EV-72-z5pk	4f53cda18c	—
Reg: laser/radiation	Laser and any ionising equipment safety	Every laser checked	Not met	0	EV-73-z5pk	1272fec6d1	LZ-1; LZ-2; LZ-3; LZ-4; LZ-5
Reg: notifiable	Notifiable disease and adverse event reporting	Sentinel event RCA within 45 days	Met	0	EV-23-z5pk	4f53cda18c	—
Reg: notifiable	Notifiable disease and adverse event reporting	MOH notice sent for every notifiable event	Met	—	EV-28-z5pk	4f53cda18c	—
Reg: PIC	Person-in-charge registered doctor named and notified	Person in charge named and notified per centre	Not met	0	EV-63-z5pk	6decc74a9d	PIC\|isec-kl; PIC\|isec-mv; PIC\|isec-pg
Reg: premises	Fire, safety, cleanliness, ventilation inspections	No safety inspection overdue	Not met	1	EV-67-z5pk	c39e90fc41	ext\|isec-mv
Reg: premises	Fire, safety, cleanliness, ventilation inspections	Inspection certificates carry their number	Not met	12	EV-68-z5pk	9fcdfd6194	airrec\|isec-kl; airrec\|isec-mv; airrec\|isec-pg; autoclave\|isec-kl; autoclave\|isec-mv
Reg: records	Patient records kept and confidential, retention	Audit trail kept	Not met	0	EV-85-z5pk	4f53cda18c	—
Reg: records	Patient records kept and confidential, retention	Data protection officers appointed	Met	100	EV-86-z5pk	0d8733c413	DPO-001; DPO-002; DPO-003; DPO-004; DPO-005
Reg: staff	Registered practitioners hold current APC	Every registered practitioner holds a current APC	Met	100	EV-54-z5pk	7e3e7eb905	HR-10; HR-100; HR-101; HR-103; HR-104
Reg: staff	Registered practitioners hold current APC	Pharmacists hold a current APC	Met	0	EV-58-z5pk	4f53cda18c	—
Reg: waste	Clinical waste handled by licensed contractor	Clinical waste consignments received (e-SWIS)	Not met	62.5	EV-74-z5pk	29db807fc9	WL-2023-10-isec-kl; WL-2023-10-isec-pg; WL-2023-11-isec-kl; WL-2023-11-isec-mv; WL-2023-11-isec-pg
4	Context, Shariah-compliance scope	Context issues reviewed	Not met	85.7	EV-43-z5pk	11f514ab0d	CTX-001; CTX-002; CTX-003; CTX-004; CTX-005
4	Context, Shariah-compliance scope	Interested parties listed	Met	9	EV-44-z5pk	d6b724d089	IPA-001; IPA-002; IPA-003; IPA-004; IPA-005
5	Leadership, Shariah committee / adviser	A published policy is on file	Met	5	EV-38-z5pk	ceca603b53	DOC-003; DOC-006; DOC-009; DOC-012; DOC-015
5	Leadership, Shariah committee / adviser	Shariah review in the last 12 months	Not met	—	EV-116-z5pk	4f53cda18c	—
7.5	Documented information	Policies and SOPs published and in review date	At risk	85	EV-36-z5pk	8fc950a366	DOC-001; DOC-002; DOC-003; DOC-004; DOC-005
8	Halal status of medicines and food	Halal status assessed for medicines	Not met	0	EV-19-z5pk	e48a74b71e	FA02BA02-01; FA02BA02-02; FA02BA03-01; FA02BA03-02; FA02BC01-01
8	Prayer facilities and Muslim-friendly care (gender, modesty)	Prayer facilities checked per centre	Not met	0	EV-115-z5pk	315ce7b598	PRY-ISEC Mid Valley; PRY-ISEC Penang
8	Staff awareness and competence in Islamic ethics	Islamic ethics awareness training current	Met	97.2	EV-51-z5pk	9c86db783e	HR-0; HR-1; HR-10; HR-100; HR-101
8	Supplier halal certification	Outsourced-service certificates complete	Not met	42.1	EV-40-z5pk	9f79c5a051	SUP-154; SUP-155; SUP-156; SUP-157; SUP-158
9.1	Customer satisfaction	Patient review scores at target	At risk	66.7	EV-49-z5pk	b24dd72568	REV-001; REV-002; REV-003; REV-004; REV-005
9.2	Internal audit	Internal audit held this quarter	Met	25	EV-46-z5pk	2709ad504e	IA-009
9.2	Internal audit	No audit finding overdue	Not met	1	EV-47-z5pk	5b893f2935	IAF-004
9.3	Management review	Management review approved in the last 12 months	Met	168	EV-48-z5pk	03621322a7	MR-001
10	Nonconformity and improvement	No incident past its due date	Not met	1	EV-22-z5pk	55b8a53e0c	INC-2610-003
10	Nonconformity and improvement	No overdue corrective action	Met	100	EV-24-z5pk	d49821bdad	CAPA-2024-01
Facility	Equipment, fire, utilities, environment	No emergency drill overdue	Met	0	EV-66-z5pk	4f53cda18c	—
Facility	Equipment, fire, utilities, environment	No safety inspection overdue	Not met	1	EV-67-z5pk	c39e90fc41	ext\|isec-mv
Facility	Equipment, fire, utilities, environment	No open temperature or humidity excursion	Met	0	EV-70-z5pk	4f53cda18c	—
Governance	Leadership, committees, policy framework	Committee met within the last quarter	Met	28	EV-34-z5pk	9fd1904502	CMM-004
Governance	Leadership, committees, policy framework	Committee decisions not overdue	Not met	1	EV-35-z5pk	9929629e07	DCL-004
Governance	Leadership, committees, policy framework	Policies and SOPs published and in review date	At risk	85	EV-36-z5pk	8fc950a366	DOC-001; DOC-002; DOC-003; DOC-004; DOC-005
Human resources	Credentials, training, performance	Competencies signed off	Met	93.6	EV-52-z5pk	84065f7abf	c10-2; c103-0; c103-1; c104-4; c104-5
Human resources	Credentials, training, performance	Every registered practitioner holds a current APC	Met	100	EV-54-z5pk	7e3e7eb905	HR-10; HR-100; HR-101; HR-103; HR-104
Human resources	Credentials, training, performance	Privileges current for every procedure	Not met	91	EV-56-z5pk	f8db5d5d27	p0-0; p0-1; p0-2; p0-3; p0-4
Infection control	Surveillance, hand hygiene, CSSD	Hand hygiene compliance	At risk	89.4	EV-6-z5pk	904d6848c5	HH-2024-01-CSSD; HH-2024-01-Day Care Unit; HH-2024-01-Eye casualty; HH-2024-01-Eye clinic; HH-2024-01-Operating theatre
Infection control	Surveillance, hand hygiene, CSSD	Sharps audits done to schedule	At risk	50	EV-29-z5pk	ba9a34e3da	SHP-001; SHP-002; SHP-003; SHP-004
Information	Records, security, indicators	Indicators meeting their target	At risk	60	EV-20-z5pk	1885d1523c	IND-bi; IND-cancel; IND-endo; IND-endoivi; IND-hh
Information	Records, security, indicators	Audit trail kept	Not met	0	EV-85-z5pk	4f53cda18c	—
Licensing	Valid facility licence and staff registrations	Every registered practitioner holds a current APC	Met	100	EV-54-z5pk	7e3e7eb905	HR-10; HR-100; HR-101; HR-103; HR-104
Licensing	Valid facility licence and staff registrations	Centre licence number on file	Not met	0	EV-59-z5pk	24e0cf2b69	B11\|bangsar-south; B11\|isec-kl; B11\|isec-mv; B11\|isec-pg; B15\|bangsar-south
Licensing	Valid facility licence and staff registrations	No centre licence expired	Met	0	EV-60-z5pk	4f53cda18c	—
Medication	Prescribing to administration, high-alert, DDA	Dangerous-drug count signed daily	Not met	0	EV-15-z5pk	018aea004d	DD-2024-01-09; DD-2024-01-10; DD-2024-01-11; DD-2024-01-12; DD-2024-01-13
Medication	Prescribing to administration, high-alert, DDA	LASA list kept (active pairs)	Met	8	EV-17-z5pk	4e460f3f09	LASA-S01; LASA-S02; LASA-S03; LASA-S04; LASA-S05
Medication	Prescribing to administration, high-alert, DDA	Medication errors classified (NCC MERP)	Met	100	EV-18-z5pk	601b1097fb	MER-2607-0001; MER-2607-0002; MER-2607-0003; MER-2607-0004; MER-2607-0005
Outcome	Clinical outcome monitoring by service	Surgeon outcome review signed	Not met	0	EV-9-z5pk	cab94db898	SUR-T.S.L.; SUR-C.J.B.; SUR-C.S.W.; SUR-F.S.K.; SUR-H.W.O.
Outcome	Clinical outcome monitoring by service	Flagged cases peer reviewed	At risk	88.9	EV-10-z5pk	49265feebc	SUR-T.S.L.; SUR-A.T.; SUR-A.A.J.S.; SUR-A.R.; SUR-B.J.
Outcome	Clinical outcome monitoring by service	PCR rate within target	Met	100	EV-109-z5pk	68198c1429	IND-pcr
Patient care	Assessment, consent, anaesthesia, discharge	WHO Sign-In signed (anaesthesia check, consent)	Not met	80.8	EV-7-z5pk	ec9ecd012f	OT-15586; OT-15587; OT-15588; OT-15589; OT-15590
Patient experience	Feedback, complaints, rights	Patient rights acknowledged in the last 90 days	Not met	0	EV-11-z5pk	4f53cda18c	—
Patient experience	Feedback, complaints, rights	Complaints answered within their due date	Met	0	EV-13-z5pk	4f53cda18c	—
Patient experience	Feedback, complaints, rights	Patient review scores at target	At risk	66.7	EV-49-z5pk	b24dd72568	REV-001; REV-002; REV-003; REV-004; REV-005
Patient safety	Safety goals, incident, sentinel review	Wristband scan or IC check before the operation	Not met	80.8	EV-1-z5pk	171b6fae19	OT-15586; OT-15587; OT-15588; OT-15589; OT-15590
Patient safety	Safety goals, incident, sentinel review	No incident past its due date	Not met	1	EV-22-z5pk	55b8a53e0c	INC-2610-003
Patient safety	Safety goals, incident, sentinel review	Sentinel event RCA within 45 days	Met	0	EV-23-z5pk	4f53cda18c	—
Quality	Indicators, audit, improvement projects	Indicators meeting their target	At risk	60	EV-20-z5pk	1885d1523c	IND-bi; IND-cancel; IND-endo; IND-endoivi; IND-hh
Quality	Indicators, audit, improvement projects	Internal audit held this quarter	Met	25	EV-46-z5pk	2709ad504e	IA-009