Accreditation Status is awarded for four years, subject to the maintenance of standards. The Hospital Survey Report that accompanies each accreditation decision is a valuable educational resource for the organization. It details those areas where the facility’s performance is commendable or needs improvement, and includes recommendations on how to meet or exceed the standards. After achieving Accreditation Status, the onus is on the healthcare facility concerned to maintain and further improve the level of performance, in accordance with the MSQH accreditation standards, which are also constantly being reviewed and updated.

A facility which has been awarded a four-year accreditation status is expected to submit two (2) progress reports to MSQH, the first at twelve (12) months and the second at thirty six (36) months from the date of  survey. While at the twenty four (24) months, a Surprise Surveillance Survey will be conducted. The Compliance Report documents for each Service contains the actions which have been taken to address surveyor comments and recommendations to improve compliance with the standards, and also includes the facility’s current assessment on the status of compliance at the time of reporting. It is mandatory to report on every standard and criteria which had been rated as 1 or 2 at the previous survey.

These reports will be reviewed by MSQH technical officers and the Executive Manager Technical and Client Services. Acceptance of the report will be based on the completeness and evidence of compliance provided.

A Surprise Surveillance Survey will be conducted at any time during the 24th months of the accreditation period, on notification by MSQH of its intention. The Facility is given a written notice fourteen (14) days before the date of the visit. The Surprise Surveillance Survey will be subsequently at the convenience of the MSQH (see Appendix IV).

In addition to regularly scheduled surveys, the MSQH reserves the right to re-survey a facility at any time in the event of the following conditions: 

  • When MSQH has reason(s) to believe that a significant breach of compliance to the standards has occurred in the facility;
  • When MSQH is advised of significant changes in the organization, e.g. change of ownership or managerial control, situation of acquisition or merger, or when the facility undergoes major infrastructure changes.

On notification by MSQH of its intention to re-survey, the healthcare facility is given a written notice to accept the re-survey within fourteen (14) days of the date of notice. The survey will subsequently be scheduled at the convenience of the MSQH. Failure to accept the re-survey will result in the withdrawal of accreditation status.

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