Resources · Readiness

Facility Readiness Checklists

Ten department-by-department checklists to walk your facility before a survey — free, no account required, cross-referenced to the ASF Standard chapter each one supports.

How to use this: these are not the ASF Standards themselves — the full criteria, with guidance and worked examples, live on the Standards pages. This is a walk-the-building companion: print a department’s checklist, take it to that department, and see what a supervisor or Coordinator would actually observe. Where a box would stay unchecked, that is a gap to close before self-assessment, not after.

Jump to a Department

1. Front Office & Reception
2. HR & Credentialing
3. Pharmacy & Medication
4. Infection Prevention & Control
5. Patient Records
6. Facilities & Life Safety
7. Emergency Preparedness
8. Governance & Leadership
9. Quality & Safety Committee
10. Discharge & Continuity

1. Front Office & Reception

Maps to: Access & Arrival / Reception & Information

Signage at the entrance is legible, in the local language, and directs a first-time visitor without needing to ask staff twice.
Registration staff can state the facility’s patient rights statement in their own words, not just point to a poster.
Waiting times are tracked and a target is displayed publicly.
A process exists for patients who cannot pay at registration — documented, not improvised case by case.
Interpreter access (in person, phone, or list of staff languages) is available and staff know how to activate it.
Complaints/feedback box or channel is visible from the reception desk, not hidden.
Emergency cases are visibly fast-tracked ahead of routine registration — staff can describe how.
Billing and pricing information is available in writing before a patient commits to a paid service.

2. Human Resources & Credentialing

Maps to: Governance & Management

Every clinical staff member’s licence/registration has been verified directly with the issuing body, not just collected as a copy.
A signed job description exists for every role, matched to what the person actually does.
Mandatory training completion is tracked centrally — not left to individual memory.
New-starter induction covers fire safety, infection control, and incident reporting before independent duties begin.
Locum, agency, or visiting staff are checked to the same credentialing standard as permanent staff.
A personnel file exists for every staff member, complete and accessible to an auditor within minutes.
Performance/competency review happens at a defined interval, documented, not just when a problem arises.
A named person is responsible for tracking licence renewal dates before they lapse.

3. Pharmacy & Medication Management

Maps to: Care & Treatment

High-alert medications (insulin, opioids, anticoagulants, concentrated electrolytes) are stored and labelled distinctly from look-alike/sound-alike drugs.
A current, dated medication list exists per patient and is reconciled at every transition of care.
Controlled substances are stored under dual control with a reconciled register, checked on a fixed schedule.
Expired or damaged stock is quarantined and disposed of through a documented process, not simply discarded.
Verbal orders are read back and confirmed before administration.
A process exists for reporting and reviewing medication errors without blaming the person who reports.
Cold-chain medications have a monitored, logged temperature record — not just a fridge with no log.
Patients receive written information about new medications at discharge, in a language they understand.

4. Infection Prevention & Control

Maps to: Safety & Emergency Preparedness

Hand hygiene compliance is observed and measured on a schedule, with results visible to staff.
Personal protective equipment is available at point of use, not in a locked store down the corridor.
A written isolation/precautions protocol exists and staff can describe when to use it.
Reusable equipment reprocessing (sterilisation, high-level disinfection) follows a documented, auditable cycle.
Sharps and biomedical waste are segregated, colour-coded, and disposed of through a licensed route.
Outbreak or cluster detection has a defined trigger and a named person who acts on it.
Staff vaccination status for relevant diseases is tracked, not assumed.
Environmental cleaning has a written schedule with sign-off, not an informal routine.

5. Patient Records & Documentation

Maps to: Care & Treatment / Governance & Management

Every patient has a unique identifier used consistently across every department and every record.
Records are legible, dated, timed, and signed — paper or electronic.
Critical/abnormal results have a documented notification pathway with a time target.
Record access is limited to those with a legitimate care role, with an audit trail for electronic systems.
Retention periods are defined and followed — records are neither destroyed early nor kept indefinitely without reason.
A backup/continuity plan exists for records in the event of system failure or fire.
Discharge summaries are completed before the patient leaves, not days later.
Patients can request and receive a copy of their own record through a defined process.

6. Facilities, Equipment & Life Safety

Maps to: Environment & Shared Spaces

Fire extinguishers, alarms, and exit signage are inspected on a documented schedule.
Emergency exits are unobstructed and unlocked from the inside at all times the facility is occupied.
Medical equipment has a maintenance and calibration schedule with dated records, not a sticker that has expired.
Backup power (generator or equivalent) is tested on a fixed schedule and covers life-critical areas.
Water and medical gas supply have documented contingency plans for interruption.
Structural and equipment safety hazards identified in the last inspection have a tracked closure date.
Accessibility for patients with disabilities is addressed — ramps, signage, accessible toilets — not assumed adequate.
A named person owns facilities safety and can produce the inspection records on request.

7. Emergency Preparedness & Mock Drills

Maps to: Safety & Emergency Preparedness

A written emergency response plan exists covering fire, mass casualty, and utility failure at minimum.
Mock drills are conducted on a fixed schedule, not only after an incident or before a survey.
Every mock drill produces a written report: actions taken, roles, gaps found, corrective action, closure date.
Staff can state the facility’s emergency code or alert system without checking a poster.
A specific plan exists for infant/patient elopement or abduction risk, where relevant to the facility type.
Cardiac/medical emergency response (crash cart, resuscitation team activation) is tested, not only stocked.
External emergency services (ambulance, fire, police) contact details are current and tested at least annually.
Lessons from the last real emergency or drill have visibly changed a policy or a layout.

8. Governance & Leadership

Maps to: Governance & Management

Organisational structure and lines of accountability are documented and known to staff, not just to management.
Leadership reviews quality and safety data on a fixed schedule, with minutes kept.
A conflict-of-interest declaration exists for anyone in a purchasing or clinical-governance role.
Policies are version-controlled, dated, and reviewed on a defined cycle — not written once and forgotten.
A budget exists for quality improvement activity, not just clinical operations.
Regulatory and licensing status is current, filed, and accessible on request.
Whistleblowing/concern-raising has a defined channel that does not require going through a direct supervisor.
The facility can name who is legally and operationally accountable if something goes seriously wrong.

9. Quality & Patient Safety Committee

Maps to: Governance & Management / Aftercare & Follow-up

A quality/patient safety committee meets on a fixed schedule with a quorum requirement and minutes.
Incident reports are reviewed for patterns, not just closed one at a time.
At least one root-cause analysis has been completed and acted on in the last cycle.
Patient/family feedback (compliments and complaints) is a standing agenda item, not an occasional mention.
A defined set of quality indicators is tracked over time and shown to staff, not just to management.
Corrective actions from the last external or internal review have documented closure evidence.
Frontline staff are represented on or consulted by the committee, not only senior management.
The committee’s work connects visibly to the facility’s Improvement Plan.

10. Discharge & Continuity of Care

Maps to: Aftercare & Follow-up

Discharge criteria are documented and checked before a patient leaves, not assumed by habit.
Patients receive written discharge instructions in a language and format they can use.
Follow-up appointments or referrals are booked or clearly arranged before discharge, not left to the patient.
A process exists to reach patients who miss a critical follow-up.
Medication changes at discharge are explained to the patient and reconciled against their prior list.
Transfer to another facility includes a written summary that travels with the patient.
Readmission within a defined window is reviewed to check whether the original discharge was premature.
Patients know who to contact after discharge if a problem arises — and that number actually works.

Need a report format for the drill itself? See the Mock Drill Report Templates — fillable formats for Fire, Medical Emergency, and Missing Person drills.

Next Step

Once you have walked each department, run the full self-assessment for your facility type to see exactly which ASF criteria each gap maps to, and get a complete gap report.

Run the Free Self-Assessment
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