The survey team arrives in the morning, the Chief Surveyor briefs your representatives, and surveyors interview the person in charge of each area, observe the work and review a random sample of documents. It ends with a summation briefing, and the accreditation decision is made later by two councillors.
The shape of the day
An MSQH technical officer contacts the person in charge at least four weeks before the survey to agree the logistics and the schedule.1 On the day, the Chief Surveyor confirms that all documentation is available and allocates surveyors to the agreed schedule, and the team interviews, observes and reviews, with the team interviews the most important part.1
What surveyors do, and what to show
| Part of the day | What happens | What to have ready |
|---|---|---|
| Pre-survey briefing | The Chief Surveyor explains roles and confirms documents | Your representatives, the schedule, the survey room |
| Team interviews | The person in charge of each area answers for its rating | The evidence index, and the records behind it |
| Staff interviews | Staff are asked how they work, to check practice matches policy | Staff who know where the SOPs and records are |
| Observation | Surveyors watch the workflow without interfering | An ordinary clinic day |
| Document review | A random review of what supports each rating | Documents indexed, records retrievable in minutes |
| Summation briefing | Major findings and ways to improve, led by the Chief Surveyor | The person in charge and managers |
Surveyors give no indication of the accreditation status they will recommend, and after the summation briefing there is no further contact between the clinic and the team about the findings.1 The Chief Surveyor sends ratings and recommendations to MSQH within one week, and two councillors score the anonymised report.1
- Agree the schedule. Plan the day around clinic work, and send the tentative schedule with the survey questionnaires at least eight weeks before.
- Prepare the room. A secured room near the team, with the indexed documents and a screen to open live records.
- Brief every area lead. Each person in charge of an area knows their ratings, their evidence and where it lives.
- Keep the clinic running. Surveyors observe real work, so keep patients booked and the day ordinary.
- Log every request. Note each item a surveyor asks for, who produced it and how long it took.
- Use the summation briefing. It is the last place to clarify a finding, so bring the person in charge and the managers.
- Time ______ Surveyor ______ Area ______
- Asked for ______
- Produced by ______ From ______ Minutes taken ______
- Follow-up needed ______ Owner ______
Questions surveyors commonly ask
- How do you identify and prioritise an urgent patient at the front desk?
- Show me a sample of medical records with the reason for visit, assessment and outcome.
- Who can see patient records, and where is your SOP on access?
- How is informed consent obtained, and where is it written?
- Show me your last incident report, the analysis and the action taken.
- Where do patients complain, and what did you change because of a complaint?
These follow the criteria in the MSQH Medical Clinic Standards.2 Next, incident and complaints handling, or back to the MOH and MSQH hub.
Questions
Do surveyors tell you the result on the day?
No. They give a general view of compliance at the summation briefing, and the accreditation status is decided by two MSQH councillors from the anonymised report.
Can surveyors take documents away?
Only with the expressed consent of the person in charge, preferably in writing.
Can a clinic appeal the decision?
Yes, within 30 days of the result, on grounds such as an inaccurate report or evidence not considered. The original status stands during the appeal.
Sources
- 1Malaysian Society for Quality in Health, 2024Medical Clinic Accreditation Survey Process Guide, March 2024Read source
- 2Malaysian Society for Quality in Health, 2024Medical Clinic Standards, 2nd editionRead source
Written by the wai team from the Ministry of Health Malaysia and the Malaysian Society for Quality in Health guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither the Ministry of Health nor MSQH endorses wai or any software.