My e-HAP

My e-HAP

Back to Main Page

Application for Accreditation Survey

Application for MSQH 3rd Edition Chronic Dialysis Accreditation Survey

The undersigned hereby applies for an Accreditation Survey by Malaysian Society for Quality in Health (here in after called MSQH).
The undersigned agrees to facilitate the surveyors appointed by the MSQH to survey the premises, facilities, organisation and operations, including documentation.
The undersigned hereby acknowledge to have read the Accreditation Survey Application terms and conditions and agrees to all of them.
The undersigned certifies that the contents of this application form are true and correct.

All fields marked with (*) are required.
Upload file : Only *.pdf is allowed. Maximum size for each file is 10MB.

CREATE LOGIN ID

Create new Login ID to access this system. I already have Login ID.

*Login ID / Email:

use email as Login ID. example: user001@gmail.com

FACILITY PROFILE

*Facility Name:

*Corporate Ownership:

*Mailing Address:

*Postcode:

*City:

*State:

Phone No.:

Fax No.:

Email:

Website:

Contact Person

Name:

Phone No.:

Email:

Customer Informations

*Organisation is listed as below Standalone Chronic Dialysis Centre:

Facility/Hospital License:

Upload file

FACILITY DETAILS

Please complete the following details so that the MSQH better assess the composition of the survey team and the length of survey required.

*The Chronic Dialysis Centre opened in the year:

and currently has the following number of dialysis stations where applicable (*please specify number in each type). Please note all dialysis stations must be declared. Should there be any changes prior to the survey, contact the MSQH as soon as possible.

1.	Number of Non Infection Dialysis Station
2.	Number of Hepatitis C Dialysis Station
3.	Number of Hepatitis B Dialysis Station
4.	Number of Hepatitis B and C Dialysis Station
5.	Others infection cases Dialysis Station (MRSA, HIV)
Total Dialysis Station		0

The chronic dialysis centre has been surveyed previously (if applicable)

#	Cycle	Date of Survey
-

Number of staff

1.	Medical Officer Please specify:
2.	Staff Nurse/Assistant Medical Officer (with post basic haemodialysis) Please specify:
3.	Staff Nurse/Assistant Medical Officer Please specify:
4.	Others staff Please specify:

LIST OF SERVICE STANDARD

*I hereby declare and would like the following services to be surveyed for accreditation.

Yes

*Please select service standards below to indicate the department of functions available:

#	Service Standard
-

Total No. of Services:: 0

MISCELLANEOUS

Please provide details of major changes in dialysis stations numbers, roles, extra services etc since last survey. (if applicable):

Does chronic dialysis centre have any subsidiary units under its current management structure? If so please detail the name, dialysis station numbers, type of dialysis machine and distance from the main facility.:

Please provide the following details separately as applicable:

REVERSE OSMOSIS SYSTEM

REPROCESSING RE-USE DIALYSER

ADEQUACY OF DIALYSIS TREATMENT

Other relevant information which may help in the allocation of number of survey days and surveyors:

DECLARATION

On behalf of the above facility, I hereby accept the terms and conditions of the above application as stated and declare that the contents are true and correct.
Terms and Conditions

Person In Charge / Medical Director

*Name:

Date:: 21/11/2024

Application for Accreditation Survey

Application for MSQH 3rd Edition Chronic Dialysis Accreditation Survey

Success!

LOGIN