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Accreditation Status
- At the accreditation survey, the surveyors identify and commend on areas of excellence as well as highlight any opportunities for improvement, using currently accepted standards as the benchmark. The observations of the surveyors, together with individual recommendations on the accreditation status by each member of the survey team are collated by the Chief Surveyor, who will forward this composite result with a final Chronic Dialysis Treatment Survey Report to MSQH.
- The final accreditation status decision is made based on a review of the Chronic Dialysis Treatment Survey Report and recommendations of the survey team by a panel of two (2) Councillors, selected from the members of the Malaysian Council of Healthcare Standards (Chronic Dialysis), a body chaired by the National Kidney Foundation Malaysia.
- Names of organisation shall be expunged before the survey report are sent to the Councillor for voting. Each Councillor vote on the report individually and they are not informed who the other councillors are. The results from the three (3) Councillors are then aggregated by the MSQH Secretariat. This will determine the Accreditation Status of the organisation.
- Three categories of Accreditation awards may be awarded, depending on the level of compliance to standards attained by the healthcare facility which is undergoing the accreditation survey process
Four-year Accreditation
A four-year Accreditation is awarded to those facilities, which in the opinion of MSQH, substantially comply with the MSQH healthcare standards. It should be noted that the healthcare facility must achieve substantial compliance in all Core Standards and other Safety Standards, to achieve four (4) - year Accreditation.
Delayed Accreditation
A Delayed Accreditation is awarded to those facilities which have met the requirements of most of the standards.
A facility awarded a delayed accreditation is offered the opportunity to undergo a Re-Assessment within the six (6) months period.
During the re-assessment, only those areas of deficiency noted in the initial survey are visited. However, this does not exclude visits to other areas deemed relevant by the surveyors.
The facility should have taken action on the recommendations which were recorded by the surveyors at the initial survey, and should achieve substantial compliance to MSQH standards in order to qualify for the four year award.
Non-Accreditation
Accreditation cannot be awarded to a facility in which the surveyors have observed and reported that a significant number of standards are not complied with. Facilities who are not accredited are encouraged to implement the recommendations made in the Survey Report and to re-apply for survey. It is recommended that a minimum of twelve (12) months should elapse, to allow time for remedial actions and rectification works, before the next survey is undertaken.
The final award decision and the recommendations are forwarded by MSQH to the Chief Executive Officer (CEO), the owner, or the chair of the governing body of the surveyed facility. Release of any confidential information pertaining to the facility will be subject to written consent from the CEO, the owner or the chair of the governing body.
