MSQH STD 20

MSQH Malaysian Hospital Accreditation Standards & Assessment Tool 6th Edition 2021 | VER. 1.
SURVEY ITEM & SELF-ASSESSMENT
SERVICE STANDARD 20 : HOUSEKEEPING SERVICES
PREAMBLE
The Housekeeping Services may be provided from within the Facility by either own staff or contract staff. The services may also be contracted to a
qualified external contractor. In this situation, the standards and criteria mentioned below and those standards for Prevention and Control of
Infection are also applicable.
TOPIC 20.1: ORGANISATION AND MANAGEMENT
STANDARD The Housekeeping Services are organised and administered to provide a pleasant, safe and sanitary environment in support of the optimum care
20.1.1 for patients according to the goals and objectives of the Healthcare Facility.
SURVEYOR FINDINGS
SELF
CRITERIA FOR COMPLIANCE:
RATING AREAS FOR IMPROVEMENT / SURVEYOR
RECOMMENDATIONS & RISK ASSESSMENT RATING
20.1.1.1 Vision, Mission and values statements of the Facility are accessible. Goals and
objectives that suit the scope of the Housekeeping Services are clearly documented and
measurable. These reflect the roles and aspirations of the service and the needs of the
community. These statements are monitored, reviewed and revised as required
accordingly and communicated to all staff.
1. Vision, Mission and values statements of the Facility are

available, endorsed and dated by the Governing Body.
2. Goals and objectives of the Housekeeping Services in line with
COMPLIANCE
EVIDENCE OF
the Facility statements are available, endorsed and dated.

3. Evidence of planned reviews of the above statements.
4. These statements are communicated to all staff (orientation

programme, minutes of meeting, etc)
SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 1 of 20

MSQH Malaysian Hospital Accreditation Standards & Assessment Tool 6th Edition 2021 | VER. 1.1
SURVEYOR FINDINGS
SELF
CRITERIA FOR COMPLIANCE: AREAS FOR IMPROVEMENT / SURVEYOR
RATING
5. Achievement of goals and objectives are monitored, reviewed
and revised accordingly.
Facility Comments:
20.1.1.2 There is an organisation chart which:

CORE a) provides a clear representation of the structure, function and reporting relationships
between the Head and staff of Housekeeping Services;
b) is accessible to all staff and clients;
c) includes off-site services if applicable;
d) is revised when there is a major change in any of the following:
i) organisation;
ii) functions;
iii) reporting relationships;
iv) staffing patterns.
1. Clearly delineated current organisation chart with line of

functions and reporting relationships between the Head and staff
of Housekeeping Services.
EVIDENCE OF
COMPLIANCE
2. Organisation chart of the service is endorsed, dated and

accessible.
3. The organisation chart is revised when there is a major change
in any of the items (d)(i) to (iv).
Facility Comments:
20.1.1.3 Regular staff meetings are held between the Head of Service and staff with sufficient
regularity to discuss issues and matters pertaining to the operations of the Housekeeping
Services. Minutes are kept; decisions and resolutions made during meetings shall be
accessible, communicated to all staff of the service and implemented.
1. Minutes are accessible, disseminated and acknowledged by the

EVIDENCE OF
COMPLIANCE
staff.
2. Attendance list of members with adequate representatives of the
service.

SURVEYOR FINDINGS
SELF
RATING
3. Frequency of meetings as scheduled.
4. Discussion and resolutions are implemented (Problems not
solved to be brought forward in the next meeting until resolved).
Facility Comments:
20.1.1.4 The Head of Housekeeping Services is involved in the planning, justification and
management of the budget and resource utilisation of the services.
1. Minutes of Facility-wide management meeting

EVIDENCE OF
COMPLIANCE
2. Documented evidence on request for allocation of budget and

resources (staffing, equipment, etc) for the service.
3. Approved budget and resources.
Facility Comments:
20.1.1.5 The Head of Housekeeping Services is involved in the appointment and/OR assignment
of staff.
1. Records on staff interview (if applicable)

2. Appointment/assignment letter of Head of Service
EVIDENCE OF
COMPLIANCE
3. Job description of Head of Service

4. Records on staff deployment
5. Duty roster
Facility Comments:
20.1.1.6 Appropriate statistics and records shall be maintained in relation to the provision of
Housekeeping Services and used for managing the services and patient care purposes.
1. Records are available but not limited to the following:
a) workload/census;
EVIDENCE OF
COMPLIANCE
b) annual report;
c) accident/incident reports;
d) staffing number and staff profile;

SURVEYOR FINDINGS
SELF
RATING
e) staff training records;
f) data on performance improvement activities, including
performance indicators;
g) customer feedback;
h) audit inspection records.
Facility Comments:
20.1.1.7 Where services are provided by an external source, there is a written agreement
CORE between the external service provider and the Facility stating the requirements for
service delivery, including the following:
a) formal lines of communication and responsibilities between the external service

provider and the Facility;
b) provision of adequate numbers of appropriately qualified personnel to perform
their duties;
c) participation, as appropriate, of the external service provider in committees of the
Facility i.e. Prevention and Control of Infection;
d) arrangement for adequate pick-up and delivery;
e) arrangements for after-hours and emergency services;
f) mechanisms for dealing with problems in service delivery;
g) adequate facilities and equipment for providing the services at the Facility and at
the site of the external service;
h) involvement of the external service provider in safety and performance
improvement activities of the Facility, as appropriate;
i) comply with the appropriate MSQH Standards of Accreditation for Housekeeping
Services which function within the Facility.
1. Written agreement which include items (a) to (i) between the
external service provider and the Facility is endorsed, signed
EVIDENCE OF
COMPLIANCE
and dated.
2. Written agreement between the external service provider and its
sub-contractors is signed and dated. The agreement is endorsed
and consented by the Facility.

SURVEYOR FINDINGS
SELF
RATING
3. Evaluation of vendor for appointment
Facility Comments:
20.1.1.8 Where services are provided by an external source, the Person In Charge (PIC) of the
CORE Facility shall appoint a person to supervise, monitor and provide technical input to the
housekeeping services.
1. Appointment letter of liaison officer with terms of reference.

EVIDENCE OF
COMPLIANCE
2. Job description
Facility Comments:

TOPIC 20.2 HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

STANDARD The Housekeeping Services shall be directed and adequately staffed with appropriately qualified and trained personnel to achieve the goals and
20.2.1 objectives of the services.
SURVEYOR FINDINGS
SELF
20.2.1.1 The Head and staff of the Housekeeping Services shall be individuals qualified by
education, training, and experience to commensurate with the requirements of the
various positions.
1. Records on qualification and experience of Head of Service and
EVIDENCE OF
COMPLIANCE
staff related to housekeeping services

2. Appointment/assignment letters
3. Training and competency records
Facility Comments:
20.2.1.2 The authority, responsibilities and accountabilities of the Head of Housekeeping

Services are clearly delineated and documented.
1. Appointment/assignment letter for Head of Service.
EVIDENCE OF
COMPLIANCE
2. Description of duties and responsibilities.
Facility Comments:
20.2.1.3 Sufficient numbers of personnel and support staff with appropriate qualifications and
CORE experience are employed to meet the need of the services.
1. Number of staff and qualification and experience
commensurate with workload.
EVIDENCE OF
COMPLIANCE
2. Staffing pattern
3. Duty roster
4. Census on workload

SURVEYOR FINDINGS
SELF
RATING
Facility Comments:
20.2.1.4 There are written and dated specific job descriptions for all categories of staff that
include:
a) qualifications, training, and experience required for the position;
b) lines of authority;
c) accountability, functions and responsibilities;
d) reviewed when required and when there is a major change in any of the following:
i) nature and scope of work;
ii) duties and responsibilities;
iii) general and specific accountabilities;
iv) qualifications required
v) staffing patterns;
vi) Statutory Regulations.
1. Updated specific job description is available for each staff that

includes but not limited to as listed in (a) to (d).
2. Job description includes specialisation skills.
EVIDENCE OF
COMPLIANCE
3. Relevant authorisation granted where applicable (e.g.

operating specialised equipment
4. The job description is acknowledged by the staff and signed
by the Head of Service and dated.
Facility Comments:
20.2.1.5 Personnel records on training, staff development, leave and others are maintained for
every staff.
Note:
Staff personal record may be kept in Human Resource Department as per Facility policy.

SURVEYOR FINDINGS
SELF
RATING
1. Staff personal records include:
a) staff biodata;
b) qualification and experience;
EVIDENCE OF
COMPLIANCE
c) training records on infection control, and technical
aspects, e.g. spillage management, safety and health;
d) competency record and authorisation for specialised
equipment;
e) leave record;
f) confidentiality agreement;
g) immunisation records.
Facility Comments:
20.2.1.6 Provision of vaccination programmes for all staff exposed to sharps injury and biological
CORE hazards.
1. Vaccination programme
EVIDENCE OF
COMPLIANCE
2. Vaccination records
Facility Comments:
20.2.1.7 There is a structured orientation programme where new staff are briefed on their
CORE services, operational policies and relevant aspects of the Facility to prepare them for
their roles and responsibilities.
1. Policy requiring all new staff to attend a structured orientation
programme.
EVIDENCE OF
COMPLIANCE
2. Records on structured orientation programme

3. Orientation Brief
4. List of attendance
Facility Comments:

SURVEYOR FINDINGS
SELF
RATING
20.2.1.8 There is evidence of training needs assessment and staff development plan which
provides the knowledge and skills required for staff to maintain competency in their
current positions and future advancement.
1. Training needs assessment is carried out and gaps identified.

2. A staff development plan based on training needs assessment
EVIDENCE OF
COMPLIANCE
is available.
3. Training schedule/calendar is in place.
4. Training module
Facility Comments:
20.2.1.9 There are continuing education activities for staff to pursue professional interests and to
prepare for current and future changes in practice.
1. Continuing education activities and schedule

EVIDENCE OF
2. Contents of training programme

COMPLIANCE
3. Training records on continuing education activities are kept and

maintained for each staff.
4. Certificate of attendance
Facility Comments:
20.2.1.10 Staff receive evaluation of their performance at the completion of the probationary period
and annually thereafter, or as defined by the Facility.
1. Performance appraisal for staff is completed upon probationary

EVIDENCE OF
COMPLIANCE
period and as an annual exercise.
Facility Comments:

TOPIC 20.3: POLICIES AND PROCEDURES
STANDARD There are documented policies and procedures that reflect current knowledge and practice of the services and are consistent with the goals and
20.3.1 objectives of the Housekeeping Services and relevant regulations and statutory requirements.
SURVEYOR FINDINGS
SELF
RATING
20.3.1.1 There are written policies and procedures for the Housekeeping Services which are
CORE consistent with the overall policies of the Facility, regulatory requirements and current
standard practices. These policies and procedures are signed, authorised and dated.
There is a mechanism for and evidence of a periodic review at least once in every three
years.
1. Documented policies and procedures for the service.
2. Policies and procedures are consistent with regulatory
EVIDENCE OF
COMPLIANCE
requirements and current standard practices.

3. Evidence of periodic review of policies and procedures.
4. The policies and procedures are endorsed and dated.
Facility Comments:
20.3.1.2 Policies and procedures are developed by a committee in collaboration with staff,
Infection Control Committee, Management and where required with other external
service providers and with reference to relevant sources involved.
Cross departmental collaboration is practised in developing relevant policies and
procedures where applicable.
1. Minutes of committee meetings on development and revision on
policies and procedures.
EVIDENCE OF
COMPLIANCE
2. Minutes of meeting with evidence of cross reference with other

departments
3. Documented cross departmental policies
Facility Comments:

SURVEYOR FINDINGS
SELF
RATING
20.3.1.3 Current policies and procedures are communicated to all staff.
1. Training and briefing on the current policies and

EVIDENCE OF procedures/Minutes of meetings
COMPLIANCE
2. Circulation list and acknowledgement
Facility Comments:
20.3.1.4 There is evidence of compliance with policies and procedures.

CORE
1. Compliance with policies and procedures through:
a) interview of staff on practices;
EVIDENCE OF
COMPLIANCE
b) verify with observation on practices;

c) results of audit on practices;
d) practices in line with established policies and
procedures.
Facility Comments:
20.3.1.5 Copies of policies and procedures, protocols, guidelines, relevant Acts, Regulations, By-
Laws and statutory requirements are accessible to staff.
1. Copies of policies and procedures, protocols, guidelines,

EVIDENCE OF
COMPLIANCE
relevant Acts, Regulations, By-Laws and statutory requirements

are accessible on-site for staff reference.
Facility Comments:
20.3.1.6 Policies and procedures for the Housekeeping Services shall include the following:

SURVEYOR FINDINGS
SELF
RATING
a) routine and special-purpose cleaning;
b) colour coding for cleaning material/apparatus;
c) provision of designated staff for specific areas such as emergency rooms, labour-
delivery rooms, nurseries, surgical suites, critical care units, intensive care units,
recovery rooms etc;
d) the use, cleaning and care of equipment;
e) the measurement, labeling, storage, and proper use of housekeeping chemicals
and cleaning supplies including germicides;
f) evaluation of cleaning effectiveness;
g) collection, segregation and disposal of waste according to statutory requirements;
h) safety and health aspects, e.g. use of personal protective equipment (PPE).
1. Policies and procedures on Housekeeping Services that

address but not limited to items (a) to (h) are available.
2. Written instructions on the following:-
a) routine and special-purpose cleaning, e.g. isolation
room (negative and positive pressure), critical areas,
e.g. operating theatre, nursery, haemodialysis unit etc;
b) prohibition of dry dusting and sweeping in the hospital;
COMPLIANCE
EVIDENCE OF
c) colour coding of mops and other cleaning materials;

d) cleansing schedule with frequency;
e) list of chemicals recommended by Hospital Infection
and Antibiotic Control Committee;
f) audit and inspection procedures;
g) collection route for general and hazardous waste and
designated dump sites;
h) segregation of solid waste, if applicable.
Facility Comments:
20.3.1.7 Storage areas comply with Safety Programmes and Fire Safety requirements as in the
Environmental and Safety Services, Standard No.2.

SURVEYOR FINDINGS
SELF
RATING
1. Policy on handling and storage of chemicals as per regulatory
requirement and standards i.e. Department of Occupational
Safety and Health (DOSH) requirements.
EVIDENCE OF
COMPLIANCE
2. Dedicated chemical storage areas with good ventilation system,
washing facilities and appropriate Personal Protective
Equipment (PPE).
Facility Comments:

TOPIC 20.4: FACILITIES AND EQUIPMENT
STANDARD There are safe and adequate facilities and equipment to enable the Housekeeping Services to meet its goals and objectives and ensuring patient
20.4.1 and staff safety.
SURVEYOR FINDINGS
SELF
20.4.1.1 There are adequate and appropriate facilities and equipment with proper utilisation of
space to enable staff to carry out their professional and administrative functions.
1.Adequate and proper utilisation of space:

a) adequate storage space;
b) dedicated routes for waste collection;
c) designated wash and drying areas for mop heads.
EVIDENCE OF
COMPLIANCE
2. Appropriate type of equipment:

a) adequate and appropriate PPE for housekeeping staff;
b) covered housekeeping trolley.
3. Easy access and clear exit routes
4. Absence of overcrowding
5. Appropriate staff change rooms with shower and lockers
Facility Comments:
20.4.1.2 There is documented evidence that equipment complies with relevant

national/international standards and current statutory requirements.
1. Testing, commissioning and calibration records (certificates or

stickers)
EVIDENCE OF
COMPLIANCE
2. Certification of equipment from certified bodies, e.g. Standards

and Industrial Research Institute of Malaysia (SIRIM), etc as
evidence of compliance to the relevant standards and Acts.
Facility Comments:

SURVEYOR FINDINGS
SELF
RATING
20.4.1.3 There is evidence that the facility has a comprehensive maintenance programme such
CORE as planned preventive maintenance and calibration activities, to ensure the facilities and
equipment are in good working order.
1. Planned Preventive Maintenance records such as schedule,

stickers, etc.
EVIDENCE OF
COMPLIANCE
2. Calibration records
3. Planned Replacement Programme where applicable
4. Repair and maintenance records
5. Asset inventory/master list of equipment
Facility Comments:
20.4.1.4 Where specialised equipment is used, there is evidence that only staff who are trained
and authorised by the Facility operate such equipment.
1. User training records
2. Competency assessment record
EVIDENCE OF
COMPLIANCE
3. Letter of authorisation
4. List of staff trained and authorised to operate specialised
equipment
Facility Comments:
20.4.1.5 Solution, cleaning chemicals and hazardous substances shall be properly labeled and
CORE stored in safe places as per Material Safety Data Sheet (MSDS) or Chemical Safety
Data Sheet.
1. MSDS records
EVIDENCE OF
COMPLIANCE
2. Chemical master list

3. Chemical store with washing facilities and adequate
ventilation.
Facility Comments:

TOPIC 20.5: SAFETY AND PERFORMANCE IMPROVEMENT ACTIVITIES
STANDARD The Head of Housekeeping Services shall ensure the provision of quality performance with staff involvement in the continuous safety and
20.5.1 performance improvement activities of the Housekeeping Services.
SURVEYOR FINDINGS
SELF
20.5.1.1 There are planned and systematic safety and performance improvement activities to
monitor and evaluate the performance of the Housekeeping Services. The process
includes:
a) Planned activities
b) Data collection
c) Monitoring and evaluation of the performance
d) Action plan for improvement
e) Implementation of action plan
f) Re-evaluation for improvement
Innovation is advocated.
1. Planned performance improvement activities include (a) to (f).

2. Records on performance improvement activities.
EVIDENCE OF
COMPLIANCE
3. Minutes of performance improvement meetings

4. Performance improvement studies
5. Records on innovation if available
Facility Comments:
20.5.1.2 The Head of Housekeeping Services has assigned the responsibilities for planning,
monitoring and managing safety and performance improvement to appropriate
individual/personnel within the respective services.

SURVEYOR FINDINGS
SELF
RATING
1. Minutes of meetings
EVIDENCE OF
COMPLIANCE
2. Letter of assignment of responsibilities
3. Job description
Facility Comments:
20.5.1.3 The Head of the Housekeeping Services shall ensure that the staff are trained and
complete incident reports which are promptly reported, investigated, discussed by the
staff with learning objectives and forwarded to the Person In Charge (PIC) of the Facility.
Incidents reported have had Root Cause Analysis done and action taken within the
agreed time frame to prevent recurrence.
1. System for incident reporting is in place, which include:

a) Training of staff
b) Policy on incident reporting
c) Methodology of incident reporting
d) Register/records of incidents
EVIDENCE OF
COMPLIANCE
2. Completed incident reports

3. Root Cause Analysis
4. Corrective and preventive action plans
5. Remedial measure
6. Minutes of meetings
7. Acknowledgment by Head of Service and PIC/Hospital Director
8. Feedback given to staff regarding incident reporting.
Facility Comments:
20.5.1.4 There is tracking and trending of specific performance indicators not limited to but at
CORE least two (2) of the following:
a) trend of performance score during in-house inspection/joint inspection

(Target: 80% with minimum score of 3)

SURVEYOR FINDINGS
SELF
RATING
b) customer satisfaction feedback

(Target: 80% satisfaction)
1. Specific performance indicators monitored.

EVIDENCE OF
COMPLIANCE
2. Records on tracking and trending analysis.

3. Remedial measures taken where appropriate.
Facility Comments:
20.5.1.5 Feedback on results of safety and performance improvement activities are regularly
communicated to the staff and relevant authority.
1. Results on safety and performance improvement activities are

accessible to staff.
EVIDENCE OF
COMPLIANCE
2. Evidence of feedback via communication on results of

performance improvement activities through continuing
education activities/meetings.
3. Minutes of service/unit/committee meetings
Facility Comments:
20.5.1.6 Appropriate documentation of safety and performance improvement activities is kept

and confidentiality of medical practitioners, staff and patients is preserved.
1. Documentation on performance improvement activities and

EVIDENCE OF
COMPLIANCE
performance indicators.
2. Policy statement on anonymity on patients and providers
involved in performance improvement activities.
Facility Comments:

SURVEYOR FINDINGS
SELF
RATING
20.5.1.7 There are safety and performance improvement activities that address staff safety of
CORE the outsourced service providers.
1. Staff health screening

2. Identification of health risk factors
3. Infectious diseases prevention programme/activities
4. Anti-smoking programme
5. Healthy life style campaign
6. Staff training on:
EVIDENCE OF
COMPLIANCE
a) sharps and needle stick injury management;

b) Occupational Safety and Health;
c) ergonomics;
d) biohazard waste disposal.
7. Medical check-up record
8. Post exposure management
9. Universal/standard precautions
Facility Comments:

SERVICE SUMMARY
SURVEYOR SUMMARY:
OVERALL RATING:
OVERALL RISK:

MSQH STD 20

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MSQH Malaysian Hospital Accreditation Standards & Assessment Tool 6th Edition 2021 | VER. 1.

SURVEY ITEM & SELF-ASSESSMENT

SERVICE STANDARD 20 : HOUSEKEEPING SERVICES

TOPIC 20.1: ORGANISATION AND MANAGEMENT

1. Vision, Mission and values statements of the Facility are

the Facility statements are available, endorsed and dated.

4. These statements are communicated to all staff (orientation

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 1 of 20

20.1.1.2 There is an organisation chart which:

1. Clearly delineated current organisation chart with line of

2. Organisation chart of the service is endorsed, dated and

1. Minutes are accessible, disseminated and acknowledged by the

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 2 of 20

1. Minutes of Facility-wide management meeting

2. Documented evidence on request for allocation of budget and

1. Records on staff interview (if applicable)

3. Job description of Head of Service

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 3 of 20

a) formal lines of communication and responsibilities between the external service

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 4 of 20

1. Appointment letter of liaison officer with terms of reference.

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 5 of 20

SURVEY ITEM & SELF-ASSESSMENT

TOPIC 20.2 HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

staff related to housekeeping services

20.2.1.2 The authority, responsibilities and accountabilities of the Head of Housekeeping

2. Description of duties and responsibilities.

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 6 of 20

1. Updated specific job description is available for each staff that

3. Relevant authorisation granted where applicable (e.g.

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 7 of 20

2. Records on structured orientation programme

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 8 of 20

1. Training needs assessment is carried out and gaps identified.

1. Continuing education activities and schedule

2. Contents of training programme

3. Training records on continuing education activities are kept and

1. Performance appraisal for staff is completed upon probationary

period and as an annual exercise.

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 9 of 20

SURVEY ITEM & SELF-ASSESSMENT

TOPIC 20.3: POLICIES AND PROCEDURES

requirements and current standard practices.

2. Minutes of meeting with evidence of cross reference with other

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 10 of 20

1. Training and briefing on the current policies and

20.3.1.4 There is evidence of compliance with policies and procedures.

b) verify with observation on practices;

1. Copies of policies and procedures, protocols, guidelines,

relevant Acts, Regulations, By-Laws and statutory requirements

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 11 of 20

1. Policies and procedures on Housekeeping Services that

c) colour coding of mops and other cleaning materials;

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 12 of 20

SERVICE STANDARD 20 – HOUSEKEEPING SERVICES Page 13 of 20

SURVEY ITEM & SELF-ASSESSMENT

TOPIC 20.4: FACILITIES AND EQUIPMENT

1.Adequate and proper utilisation of space:

2. Appropriate type of equipment: