Access & Arrival
Access & Arrival
MANDATORY
5 criteria
| Standard 1.1 NON-NEGOTIABLE · Standard 1: Access & Arrival Findable Before Arrival |
ASSESSMENT ASF-STD1-v3.0 |
| CR FULL | TR FULL | SM FULL | ST FULL |
| 1.1 NON-NEGOTIABLE L1 |
THE STANDARD Findable Before Arrival The facility's name, address, phone number, and mapped location are correct, current, and independently verifiable by anyone searching as a patient would. |
| HOSPITAL SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is the facility name, address, and phone number correct on your own website and any public listing? Not the address on file with a regulator years ago — what a patient searching today would actually find. Doc: Website screenshot, public listing |
YES | PARTIAL | NO |
| 2 | Does the phone number listed actually connect to your facility when called? Tested directly, not assumed because it was correct when first published. Doc: Call log or test record |
YES | PARTIAL | NO |
| 3 | If a map location is used, does the pin match the real entrance, not a nearby approximation? A pin one block off sends ambulances to the wrong street in an emergency. Doc: Map screenshot |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| OBSERVE Public search test |
Independently searches for the facility exactly as a patient would — by name, address, phone number — using only public information. |
| DOCUMENT Address cross-check |
Confirms the mapped or listed address matches what is physically found on arrival. |
| ASK Cold-call directions test |
Calls the listed number posing as a first-time patient asking for directions, and notes whether the answer is accurate without hesitation. |
REFERENCES
World Health Organization. Emergency care system framework. Geneva: WHO; 2018.
Pons PT, Markovchick VJ. Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome? J Emerg Med. 2002;23(1):43-48.
| Standard 1.1 · Standard 1: Access & Arrival Guidance & Learning |
GUIDANCE ASF-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
A facility that cannot be found cannot be reached in an emergency. Outdated addresses, dead phone numbers, and unmapped locations are a common, preventable failure that costs real time when a patient or ambulance is trying to arrive.
| WHAT GOOD LOOKS LIKE ✓ Name, address, and phone number are correct and independently verifiable. ✓ A patient can call cold and reach the front desk within a minute. ✓ The mapped pin matches the real, physical entrance exactly. |
WHAT FAILURE LOOKS LIKE ✗ An old address still listed on letterhead, alongside a correct current one online. ✗ Listed number rings out with no voicemail; no way to confirm the location at all. ✗ A map pin one street over from the real building, with no correction requested. |
| MOST COMMON REASONS HOSPITALS SCORE PARTIAL |
1 The website was never updated after a move.
The clinical team changed address but nobody told whoever manages the website — a common, low-cost, high-consequence gap.
2 The phone number is correct but nobody answers as "the facility."
Calls connect to a generic switchboard that cannot confirm this is the right place.
3 The map pin was set once, years ago, and never checked again.
Map platforms occasionally shift pins during their own updates — nobody at the facility owns checking it periodically.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Search for your own facility exactly as a patient would, across every platform patients actually use.
Week 2 Correct the address and phone number on your own website and any listing you control directly.
Week 3 Call your own listed number from an outside line and time how long it takes to confirm you've reached the right place.
Ongoing Recheck all public listings every six months.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Search cold, don't ask the facility for directions first.
The whole point is testing what a stranger finds.
Call from a number the facility won't recognise.
A number in the facility's own contact list may get special handling a real patient wouldn't.
| E-LEARNING academy.gmj.ge/std1-1-findability — 30 min · complete before self-assessment |
| Standard 1.2 NON-NEGOTIABLE · Standard 1: Access & Arrival Hospital Grounds and Territory Entrance |
ASSESSMENT ASF-STD1-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 1.2 NON-NEGOTIABLE L1 |
THE STANDARD Hospital Grounds and Territory Entrance The hospital's territory begins at its first point of entry — the gate, main entrance, or boundary of the grounds — not at the building door. This entire approach is safe, clean, and clearly the hospital's own space from that first point. |
| HOSPITAL SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is the boundary of the hospital's grounds — gate, fence line, or first entry point — clearly identifiable as the hospital's own territory? Not the building itself — the point where a visitor first enters land the hospital is responsible for. Doc: Photo of grounds boundary and entry point |
YES | PARTIAL | NO |
| 2 | Is the approach from that entry point to the building itself safe, maintained, and clean? Walkways, lighting, and general upkeep of the grounds themselves, not just the building interior. Doc: Grounds maintenance record |
YES | PARTIAL | NO |
| 3 | Is there a single, clear route from the territory entrance to the main building, not multiple ambiguous paths? A confusing arrival sequence undermines confidence before the visit has even properly begun. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| OBSERVE Grounds boundary check |
Physically walks the entire approach from the territory's first entry point to the building, checking maintenance and safety. |
| OBSERVE Route clarity test |
Approaches as a first-time visitor would, checking whether the route from entry point to building is unambiguous. |
| DOCUMENT Grounds maintenance record review |
Reviews maintenance and upkeep records for the grounds themselves, separate from building maintenance. |
REFERENCES
Ulrich RS, Zimring C, Zhu X, et al. A Review of the Research Literature on Evidence-Based Healthcare Design. HERD. 2008;1(3):61-125.
WHO, Emergency Care System Framework (2 May 2018).
| Standard 1.2 · Standard 1: Access & Arrival Guidance & Learning |
GUIDANCE ASF-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
A patient's experience of arrival doesn't start at the building door — it starts wherever the hospital's own territory begins. A neglected entrance gate, an unclear boundary, or grounds that don't visibly signal "you have arrived" undermines trust and safety before any clinical encounter even begins.
| WHAT GOOD LOOKS LIKE ✓ The grounds boundary is clearly identifiable, safe, and well maintained from the first point of entry. ✓ A single, unambiguous route leads from the entrance to the building. ✓ Lighting, walkways, and general upkeep of the grounds reflect the same standard expected inside the building. |
WHAT FAILURE LOOKS LIKE ✗ The territory boundary is unclear, with no obvious sense of where hospital responsibility begins. ✗ Grounds are neglected, poorly lit, or unsafe to walk, even though the building itself is well kept. ✗ Multiple ambiguous paths from the entrance leave a first-time visitor uncertain which way to go. |
| MOST COMMON REASONS HOSPITALS SCORE PARTIAL |
1 The building is well maintained, but the grounds have never received the same attention.
Maintenance budgets and attention often stop at the building's own walls, leaving the approach overlooked.
2 The main route is fine but a secondary or older entrance is neglected.
A less-used entrance can quietly fall out of the same maintenance cycle as the primary one.
3 Lighting is adequate during the day but poor at night, when it matters most for safety.
A daytime assessment alone can miss a genuine after-hours safety gap.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Walk the full grounds approach, from territory boundary to building, and log every maintenance or safety gap found.
Week 2 Address the highest-priority safety gaps first — lighting, walkway condition, obstruction.
Week 3 Clarify signage or physical routing so the path from entrance to building is unambiguous.
Ongoing Include grounds maintenance in the same routine inspection cycle as the building itself.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Walk the actual approach yourself, don't assess the building alone.
This standard is specifically about what happens before the building door, which is easy to overlook.
Check lighting and safety after dark if possible, not only during a daytime visit.
Genuine safety gaps often concentrate in conditions the standard assessment visit doesn't naturally cover.
| E-LEARNING academy.gmj.ge/std1-2-grounds-entrance — 30 min · complete before self-assessment |
| Standard 1.3 NON-NEGOTIABLE · Standard 1: Access & Arrival Physical Access, or a Real Plan |
ASSESSMENT ASF-STD1-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 1.3 NON-NEGOTIABLE L1 |
THE STANDARD Physical Access, or a Real Plan At least one entrance is usable by a wheelchair user without staff needing to lift or carry them. Where full access does not yet exist, the facility holds a specific, budgeted, dated plan to close the gap. |
| HOSPITAL SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is there at least one entrance a wheelchair user can use without staff physically lifting or carrying them? A step, a narrow doorway, or a heavy unassisted door all count as a barrier. Doc: Photo of entrance route |
YES | PARTIAL | NO |
| 2 | If not, is there a specific, budgeted, dated plan to close the gap? Not "we've discussed it" — a named structural change, a budget line, a date. Doc: Capital plan or board minutes |
YES | PARTIAL | NO |
| 3 | Has any real step already been taken toward that plan? A quote obtained, materials ordered, or work scheduled — not just intention. Doc: Quote, order, or contract |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| OBSERVE Physical route check |
Walks the accessible route from the street or car park to the entrance, checking for steps, doorway width, and obstructions. |
| DOCUMENT Plan verification |
If access is incomplete, requests the accessibility plan directly. |
| ASK Front-line staff interview |
Asks a front-line staff member how they would actually assist a wheelchair user arriving right now. |
REFERENCES
United Nations. Convention on the Rights of Persons with Disabilities, Article 9 — Accessibility. New York: UN; 2006.
United Nations. Convention on the Rights of Persons with Disabilities, Article 4(2) — Progressive Realisation. New York: UN; 2006.
| Standard 1.3 · Standard 1: Access & Arrival Guidance & Learning |
GUIDANCE ASF-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
Physical access is a real right, not a comfort feature — this stays Non-Negotiable. But this standard applies across very different resource realities. Treating "no ramp yet, funded plan, a date" the same as "no ramp, no plan" would make accreditation achievable only for facilities that already have money.
| WHAT GOOD LOOKS LIKE ✓ A clear, unobstructed accessible route verified on the day of assessment. ✓ A funded, dated plan with a contractor already selected and visible first steps taken. ✓ Front-line staff describe genuine, dignified assistance procedures without hesitation. |
WHAT FAILURE LOOKS LIKE ✗ "We've been meaning to build a ramp" — no document, no budget, no date, unchanged from the year before. ✗ A ramp exists on paper but is blocked by stored equipment on the day of the visit. ✗ Staff describe assistance as improvised, with no actual procedure or training behind it. |
| MOST COMMON REASONS HOSPITALS SCORE PARTIAL |
1 A ramp exists but was never checked for actual usability.
Grade too steep, surface uneven, or door at the top too heavy — built once, never tested by an actual wheelchair user.
2 A plan exists in someone's head but was never written down or costed.
Good intentions with no budget line are indistinguishable from no plan once someone asks for the document.
3 Access exists at one entrance but staff don't know to direct people there.
The infrastructure exists; the operational knowledge to use it consistently does not.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Physically test your own accessible route and document every barrier found.
Week 2 Get a real quote for the smallest fix that closes the largest gap.
Week 3 Put a specific budget line and date in front of whoever approves facility spending, in writing.
Month 2 Train front-line staff on a real, dignified assistance procedure for the gap between now and the fix.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Walk the route yourself, don't take a photo's word for it.
Grade and surface texture matter in ways photos hide.
Ask for the plan document before commenting on what you observed.
A facility that produces a real document quickly usually has a real plan.
| E-LEARNING academy.gmj.ge/std1-2-access — 30 min · complete before self-assessment |
| Standard 1.4 NON-NEGOTIABLE · Standard 1: Access & Arrival Emergency Entrance, Marked and Clear |
ASSESSMENT ASF-STD1-v3.0 |
| CR FULL | TR FULL | SM FULL | ST FULL |
| 1.4 NON-NEGOTIABLE L1 |
THE STANDARD Emergency Entrance, Marked and Clear Where the facility has a distinct emergency entrance, it is clearly marked from the approach a person would actually take, visible before arrival, and kept clear at all times. |
| HOSPITAL SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is the emergency entrance signed clearly enough to be seen before arriving at the main door? Visible from the approach a real ambulance or member of the public would take. Doc: Photo from approach point |
YES | PARTIAL | NO |
| 2 | Is the route to it kept physically clear at all times? Not just clear when checked — clear as a matter of routine. Doc: Routine clearance log, if kept |
YES | PARTIAL | NO |
| 3 | Would two different staff members give the same directions to it if asked separately? Inconsistent directions from staff usually means the signage itself is inadequate. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| OBSERVE Approach visibility test |
Approaches from the direction the public or an ambulance would arrive, checking when signage first becomes visible. |
| OBSERVE Route clearance check |
Checks whether the route beneath the signage is physically clear. |
| ASK Staff consistency test |
Separately asks two different staff members for directions, without either knowing the other was asked. |
REFERENCES
World Health Organization. Emergency care system framework. Geneva: WHO; 2018.
United Nations. Convention on the Rights of Persons with Disabilities, Article 9(1)(b). New York: UN; 2006.
| Standard 1.4 · Standard 1: Access & Arrival Guidance & Learning |
GUIDANCE ASF-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
In a genuine emergency, seconds spent finding the right door are seconds not spent on care. A sign only visible after arriving at the wrong entrance defeats its own purpose.
| WHAT GOOD LOOKS LIKE ✓ A sign is visible from the main road, before the turn into the grounds, with the route kept clear. ✓ Staff give the same, immediate, confident directions when asked separately. |
WHAT FAILURE LOOKS LIKE ✗ Signage only becomes visible once already in the car park. ✗ Two staff members give two different answers when asked directly. |
| MOST COMMON REASONS HOSPITALS SCORE PARTIAL |
1 Signage was designed for vehicles, not pedestrians, or the reverse.
A facility serving both often only signs for one.
2 The route is clear during the day and blocked by deliveries at other times.
Assessed once, on a quiet day, the gap between routine and exception can go unnoticed.
3 Signage exists but wasn't updated when the entrance itself moved.
Renovation projects change layouts faster than signage budgets get approved.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Walk and drive the actual approach routes, timing when signage becomes visible.
Week 2 Fix the single biggest visibility gap first.
Week 3 Brief all front-line and security staff on a single, consistent set of directions.
Ongoing Recheck route clearance at different times of day.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Time the approach, don't just confirm the sign exists.
A sign visible only for the last five metres fails the same way as no sign.
Ask directions from someone who isn't reception.
Reveals whether the knowledge is actually distributed.
| E-LEARNING academy.gmj.ge/std1-3-emergency-entrance — 30 min · complete before self-assessment |
| Standard 1.5 CORE · Standard 1: Access & Arrival Wayfinding Without Staff Dependence |
ASSESSMENT ASF-STD1-v3.0 |
| CR ADAPTED | TR FULL | SM ADAPTED | ST FULL |
| 1.5 CORE L1 |
THE STANDARD Wayfinding Without Staff Dependence Basic wayfinding allows someone with no prior knowledge of the building to locate reception, toilets, and the main clinical areas without stopping to ask for directions more than once. |
| HOSPITAL SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Can a first-time visitor find reception using only your posted signage? Not staff intercepting and redirecting. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 2 | Can they find the nearest toilet and one named clinical department the same way? Test this with someone who has genuinely never been inside the building before. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Is signage consistent across every floor, or does it stop after the ground floor? A common, specific failure. Doc: Photos, floor by floor |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| OBSERVE First-time visitor test |
Enters as a first-time visitor and attempts to locate reception, toilet, and one department using only signage. |
| OBSERVE Staff-query count |
Notes exactly how many times a staff member had to be asked for directions. |
| ASK Independent visitor check |
Asks a visitor already in the building whether they found their way easily. |
REFERENCES
Carpman JR, Grant MA. Design that cares: planning health facilities for patients and visitors. 3rd ed. San Francisco: Jossey-Bass/Wiley; 2016.
Ulrich RS, Zimring C, Zhu X, et al. A review of the research literature on evidence-based healthcare design. HERD. 2008;1(3):61-125.
| Standard 1.5 · Standard 1: Access & Arrival Guidance & Learning |
GUIDANCE ASF-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
This is not a comfort feature. Confusing, unsigned facilities disproportionately fail people who are anxious, in pain, unfamiliar with the local language, or accompanying someone who is.
| WHAT GOOD LOOKS LIKE ✓ Reception, toilets, and at least one clinical area are locatable by signage alone. ✓ A visitor already in the building confirms wayfinding felt straightforward. |
WHAT FAILURE LOOKS LIKE ✗ A single sign board at the main door and nothing beyond it. ✗ Ground-floor signage is clear; upper floors have none at all. |
| MOST COMMON REASONS HOSPITALS SCORE PARTIAL |
1 Signage exists but uses internal department codes, not patient-facing names.
Staff know what "Ward 4B" means; a first-time visitor does not.
2 Ground floor is signed because it was renovated recently; upper floors were never touched.
Wayfinding quality often tracks renovation history rather than a deliberate standard.
3 Signage exists in one language only, in a facility serving a multilingual population.
Technically present signage a meaningful share of visitors still cannot use.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Have someone with no prior knowledge navigate the building, and log every point of confusion.
Week 2 Fix the highest-traffic gap first.
Month 2 Extend consistent signage to every floor, using patient-facing names.
Ongoing Re-test with a genuine first-time visitor whenever the layout changes.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Use a genuinely unfamiliar tester.
Anyone with prior exposure fills gaps a true first-time visitor cannot.
Count staff queries precisely, don't estimate.
"A couple of times" and "zero times" are very different outcomes.
| E-LEARNING academy.gmj.ge/std1-4-wayfinding — 30 min · complete before self-assessment |
Hospital Standards — overviewFacility Classification — Which Type of Hospital Are You?Standard 1 — Access & ArrivalStandard 2 — Reception & InformationStandard 3 — Environment & Shared SpacesStandard 4 — Care & TreatmentStandard 5 — Safety & Emergency PreparednessStandard 6 — Aftercare & Follow-upStandard 7 — Governance & ManagementStandard 8 — Medical TourismStandard 9 — Refugee & Migrant HealthReferences & Index
Test your facility against this standard
Open self-assessment — no login, no fee.
Print to share.
