EDITIONEN·FR·ქართ
ASF Logo

Accréditation Sans Frontières

International Accreditation of Healthcare Facilities

Start accreditation  

Accréditation Sans Frontières · ASF Health Standards 9.0

Standard 4 · Care & Treatment

38 criteria · base standard

Base standard. 38 criteria, of which 29 non-negotiable. Each criterion is numbered 4.Y, with its classification and verification questions.

Criteria

4.1 Consent Is Informed, Not Only Signed

NON-NEGOTIABLE

Informed consent explains risks, benefits, and alternatives before every significant procedure — a conversation the patient can describe back, not a form signed on the way into theatre.

VERIFICATION QUESTIONS

  1. Can a patient who signed a consent form in the last month describe, in their own words, what the procedure involves?
    Not whether they signed — whether they understood.
  2. Are risks, benefits, and at least one alternative documented as discussed, not just the procedure name?
    A generic form listing the procedure only, with no discussion recorded, does not meet this.
  3. Is consent taken far enough in advance that a patient could realistically change their mind?
    Consent obtained on the trolley outside theatre is not meaningfully free.

4.2 Staff Credentials Are Checked and Current

NON-NEGOTIABLE

Every clinical staff member's qualifications are verified and on file — checked directly with the issuing or licensing body, not taken on the applicant's word — and that staff member receives structured orientation before independent practice, periodic performance and competency evaluation thereafter, and is expected to practise according to current, accepted evidence-based standards, protocols and guidelines.

VERIFICATION QUESTIONS

  1. Is every clinical staff member's licence or qualification verified directly with the issuing body?
    A photocopied certificate on file is not verification — contacting the issuer is.
  2. Are credentials rechecked on renewal, not just at hiring?
    A licence can lapse or be revoked after hiring without anyone noticing if it is never rechecked.
  3. Is there a named person responsible for credential tracking, not an informal arrangement?
    Responsibility spread across nobody in particular usually means it happens to nobody in particular.
  4. Does every new clinical staff member complete structured orientation covering role-specific procedures before practising independently, not learn the job informally from colleagues as they go?
    A structured orientation programme, not an assumption that shadowing a colleague for a few days is sufficient.
  5. Is every clinical staff member's performance and competency formally evaluated on a defined schedule, documented and shared with the staff member, not left to informal supervisor impression?
    A documented, periodic evaluation process, distinct from credential verification alone.
  6. Can staff describe the current evidence-based guideline or protocol behind a specific clinical decision they made recently, not rely on personal habit or how it has always been done?
    Demonstrated reliance on current accepted evidence, not inherited practice that is never revisited.

4.3 New Staff Are Properly Onboarded

NON-NEGOTIABLE

Mandatory induction covers safety essentials before independent work begins — a defined, checklist-based process, not learning by observation over the first few unsupervised weeks.

VERIFICATION QUESTIONS

  1. Is there a documented induction checklist covering safety essentials before independent work?
    Not a general welcome session — specific safety content, checked off item by item.
  2. Does induction happen before independent work begins, not alongside it?
    Learning safety essentials while already working unsupervised defeats the purpose.
  3. Can a recently hired staff member describe what their induction covered?
    A completed checklist with no retention suggests a formality, not training.

4.4 Staffing Matches Patient Need

NON-NEGOTIABLE

Staffing levels and skill mix are documented against patient volume and acuity — a calculation grounded in actual demand, not a fixed roster set once and never revisited.

VERIFICATION QUESTIONS

  1. Is staffing calculated against actual, current patient volume and acuity, not a fixed historical roster?
    A roster set years ago and never revisited does not reflect today's demand.
  2. Is there a defined process for escalating when staffing falls short of documented need?
    Recognising a shortfall is only useful if something happens as a result.
  3. Can staff describe what happens when they are short-staffed, beyond "we manage"?
    A vague answer usually means there is no process, just accumulated coping.

4.5 Hand Hygiene Happens

NON-NEGOTIABLE

Hand hygiene stations are present at the point of care and staff use them — observably, not only when being watched.

VERIFICATION QUESTIONS

  1. Are hand hygiene stations physically present at the actual point of care, not just at ward entrances?
    A station at the entrance to a ward does not help at the bedside where contact happens.
  2. Is compliance measured through unannounced observation, not self-report?
    Staff self-report on hand hygiene is notoriously unreliable — this needs observation.
  3. Is there a visible difference in supply availability between announced and unannounced checks?
    Stations that are well stocked only during scheduled inspections are a specific failure pattern.

4.6 Protective Equipment Is Available

NON-NEGOTIABLE

PPE is accessible at the point of use, not stored in a locked room or a location that adds friction between the need and the use.

VERIFICATION QUESTIONS

  1. Is PPE physically accessible at the point of use, without requiring a key or a walk to another area?
    Locked storage or distant supply points reduce actual use regardless of stock levels.
  2. Is appropriate PPE available for the specific transmission risk of each area, not a generic kit everywhere?
    A one-size-fits-all approach often means the wrong equipment is available where a specific risk exists.
  3. Is stock monitored so that PPE does not run out mid-shift?
    A stockout discovered mid-procedure is a preventable failure, not a supply chain inevitability.

4.7 Sharps and Waste Are Handled Safely

NON-NEGOTIABLE

Clinical waste and sharps are segregated and disposed of safely at the point of use, with containers appropriately placed rather than requiring staff to carry hazardous material any distance.

VERIFICATION QUESTIONS

  1. Are sharps containers available immediately at the point of use, not requiring staff to walk with an exposed sharp?
    Any distance travelled with an uncontained sharp is unnecessary risk.
  2. Are containers replaced before they reach unsafe fill levels, not left to overflow?
    An overfilled container is a direct, preventable injury risk.
  3. Is clinical waste segregated correctly at the point of disposal, not sorted later?
    Correct sorting after the fact requires someone to handle already-contaminated mixed waste.

4.8 Every Patient Gets a Structured Assessment

NON-NEGOTIABLE

A structured clinical assessment happens on admission — an evaluation using a defined process, not a chart entry completed to satisfy documentation requirements — performed by a qualified individual, drawing in other relevant disciplines where the patient's presentation calls for it, and documented as required by organisational policy.

VERIFICATION QUESTIONS

  1. Is a structured assessment tool used on admission, not a free-text chart entry alone?
    A structured tool ensures systematic coverage regardless of who is completing it or how busy they are.
  2. Does the assessment happen within a defined timeframe of admission, not "eventually"?
    An assessment completed a day late has already missed its window to catch early risk.
  3. Is the assessment specific to the patient, or does it show signs of being copied from a previous entry?
    Identical wording across different patients' assessments signals a formality, not an evaluation.
  4. Is the assessment performed by someone qualified to perform it, verifiable against that person's credentialed scope, not delegated informally to whoever is available?
    A named, qualified assessor, not an assessment completed by whoever happened to have a free moment.
  5. Where the patient's presentation calls for it, does the initial assessment draw in other relevant disciplines, not remain confined to a single discipline's perspective regardless of complexity?
    Multidisciplinary input when the case warrants it, not a single-discipline assessment applied uniformly regardless of need.

4.9 There is an Actual Care Plan

NON-NEGOTIABLE

A documented, individualised care plan guides treatment — built from the patient's specific assessment, not a generic template applied regardless of their particular situation — states the goals or desired results of treatment, and involves the patient, and family when appropriate, in setting it.

VERIFICATION QUESTIONS

  1. Is there a documented care plan specific to this patient's assessment findings, not a generic template?
    A plan that could apply to any patient with a similar diagnosis, unchanged, suggests it was not individualised.
  2. Does the care plan get updated as the patient's condition changes, not written once and left static?
    A care plan that never changes despite documented changes in condition has stopped functioning as a plan.
  3. Can a staff member taking over a shift find and understand the current care plan quickly?
    A plan that is hard to locate or interpret at handover fails at the exact moment it matters most.
  4. Does the care plan state explicit goals or desired results of treatment, not only a list of interventions with no stated purpose?
    A goal the plan is working toward, not just a record of what is being done.
  5. Was the patient, and family where appropriate, involved in setting the plan's goals, not only informed of a plan decided without them?
    Involvement in setting direction, not notification after the plan is already fixed.

4.10 Medication Prescribing Is Safe

NON-NEGOTIABLE

Prescriptions are checked, legible, and follow a defined safety process — including a second check for high-risk medications by a trained, designated person, whoever that is at this facility, not reliance on one clinician's judgement alone.

VERIFICATION QUESTIONS

  1. Are prescriptions legible and complete, including dose, route, and frequency, without ambiguity?
    An illegible or incomplete prescription forces the dispensing or administering staff to guess or assume.
  2. Is there a defined second-check process for high-risk medications specifically?
    General vigilance is not the same as a specific, mandatory second check for the medications most likely to cause serious harm.
  3. Are prescribing errors, when caught, tracked and reviewed, not just quietly corrected?
    A caught error that is never reviewed teaches the system nothing about why it happened.

4.11 The Surgical Safety Checklist Is Used

NON-NEGOTIABLE

WHO's Surgical Safety Checklist is completed, out loud, as a team pause for every procedure — not filed as paperwork after the fact — and includes explicit verification of correct patient, correct procedure, and correct body site, with the site physically marked before the patient enters theatre.

VERIFICATION QUESTIONS

  1. Is the checklist completed out loud, as a team, before induction, before incision, and before the patient leaves theatre?
    All three checkpoints, spoken, not just the pre-induction one done and the rest skipped.
  2. Does every team member participate, not just the most senior person present?
    A checklist read by one person to a silent room misses its purpose — catching what any team member might notice.
  3. Is there evidence the checklist has changed a decision or caught an issue, not just been completed?
    A checklist that never catches anything over time is worth questioning, not simply checking for completion.
  4. For any procedure involving laterality, multiple structures, or multiple levels, is the surgical site physically marked by the operating clinician before the patient enters theatre, and is that mark visible and verified during the time-out?
    Explicit site marking and verification, not an assumption that confirming the procedure name alone rules out wrong-site error.

4.12 Anaesthesia Is Delivered Safely

NON-NEGOTIABLE

Anaesthesia follows defined safety protocols with continuous monitoring throughout the procedure, appropriate to the level of anaesthesia and the patient's specific risk profile.

VERIFICATION QUESTIONS

  1. Is continuous monitoring maintained throughout the entire procedure, not just at induction and emergence?
    Gaps in monitoring during the middle of a long procedure are a documented risk pattern.
  2. Is the monitoring equipment appropriate to the level of anaesthesia and functioning, not just present?
    Equipment that is present but not properly calibrated or maintained provides false reassurance.
  3. Is there a defined escalation protocol for anaesthesia-related complications?
    A protocol for the routine case is not the same as a protocol for when something goes wrong.

4.13 Surgical Site Infection Is Actively Prevented

NON-NEGOTIABLE

A defined surgical site infection prevention bundle is followed for every procedure — a specific, checkable set of practices, not general good intentions about cleanliness.

VERIFICATION QUESTIONS

  1. Is a specific, defined SSI prevention bundle followed for every procedure, not general practice?
    "We're careful about infection" is not the same as a specific, checkable bundle of practices.
  2. Is the facility's own SSI rate measured and tracked?
    Improvement is not possible against a rate nobody is measuring.
  3. Is bundle compliance checked per procedure, not assumed from general training?
    General training does not guarantee the bundle was followed on any specific occasion.

4.14 The Lab Has Quality Control

NON-NEGOTIABLE

Internal quality control runs before results are released, every batch — a check against known standards, not results released on the assumption that equipment is working correctly.

VERIFICATION QUESTIONS

  1. Does internal quality control run before every batch of results is released, without exception?
    "Usually" or "when there is time" is not the same as a non-negotiable step.
  2. Is there a defined process for what happens when quality control fails?
    A QC failure needs a clear response that is followed, not ad hoc decision-making in the moment.
  3. Are QC records retained and reviewable, not just checked and discarded?
    Retained records allow pattern detection over time that a single check cannot reveal.

4.15 Critical Lab Values Reach the Doctor Fast

NON-NEGOTIABLE

Critical results are reported through a faster, distinct pathway with confirmed receipt — not released into the same queue as routine results and left for someone to eventually notice.

VERIFICATION QUESTIONS

  1. Is there a distinct, faster pathway for critical values, separate from routine result reporting?
    If critical values go into the same queue as everything else, speed depends on luck, not design.
  2. Is receipt of a critical value confirmed by the receiving clinician, not just assumed from transmission?
    A result sent is not the same as a result received and acknowledged by someone who can act on it.
  3. Is there a defined escalation if the first attempt to reach a clinician fails?
    A single failed contact attempt should not be where the process quietly stops.

4.16 Specimens Are Correctly Identified

NON-NEGOTIABLE

Specimen collection uses two identifiers, checked before collection and again before testing — a specific, doubled verification, not a single check assumed to be sufficient.

VERIFICATION QUESTIONS

  1. Are two identifiers checked before specimen collection, not just one?
    A single identifier — a bed number, for instance — is not sufficient on its own.
  2. Is identity checked again before testing, independently of the collection-time check?
    A single check at collection does not catch an error introduced afterwards, in transit or labelling.
  3. Can staff describe what happens when identifiers do not match?
    A clear stop-and-resolve process, not proceeding anyway under time pressure, is essential.

4.17 Medication Storage Is Secure and Correct

NON-NEGOTIABLE

Medications are stored at the correct temperature and access is restricted to authorised staff — a specific, verifiable set of conditions, not general good housekeeping.

VERIFICATION QUESTIONS

  1. Are temperature-sensitive medications stored within their required range, monitored and logged?
    A fridge that is "probably fine" is not the same as one with a monitored, logged temperature record.
  2. Is access to medication storage restricted to authorised staff specifically, not generally available?
    General staff access, even with good intentions, undermines accountability and control.
  3. Are storage conditions checked routinely, not only when something seems wrong?
    Routine checking catches drift before it becomes a problem; reactive checking catches it after.

4.18 High-Alert Medications Get Extra Safeguards

NON-NEGOTIABLE

Insulin, anticoagulants, and concentrated electrolytes have an independent double-check before administration — a specific, mandatory second person, not the same clinician checking their own work twice.

VERIFICATION QUESTIONS

  1. Is there a defined, named list of high-alert medications requiring an independent double-check?
    A vague sense of "being extra careful" with certain medications is not the same as a specific, named list.
  2. Is the double-check performed by an independent second person, not the same clinician?
    Self-verification does not provide the independent perspective the safeguard is designed to add.
  3. Is the double-check documented, not just assumed to have happened?
    An undocumented check leaves no way to verify it occurred as intended.

4.19 Medication Reconciliation Happens

NON-NEGOTIABLE

Admission and discharge medication lists are compared and discrepancies resolved by a trained, designated person — a documented reconciliation process, not an assumption that the lists already match, and not dependent on a clinical pharmacist role this facility may not have.

VERIFICATION QUESTIONS

  1. Is a formal reconciliation process completed at both admission and discharge, comparing medication lists directly?
    Reconciliation only at one transition point, not both, leaves a gap.
  2. Are discrepancies found during reconciliation resolved and documented, not just noted?
    Identifying a discrepancy without resolving it provides no safety benefit.
  3. Does the process include the patient's own account of what they take, not only prior records?
    Prior records can be outdated or incomplete — the patient's own current account is a necessary cross-check.

4.20 Patient Identified Correctly at Every Point of Contact

NON-NEGOTIABLE

Every patient is verified using at least two identifiers before any medication, procedure, blood product, or specimen collection — not only for laboratory work, but at every point where contact could go wrong.

VERIFICATION QUESTIONS

  1. Are two identifiers checked before every medication administration, not only during specimen collection?
    The same two-identifier discipline applied to lab work needs to extend to medication rounds.
  2. Is a room or bed number ever used as a patient identifier?
    Room and bed numbers change and are never acceptable as an identifier on their own.
  3. Is patient identification checked before blood products and before procedures, independently each time?
    Each new point of contact needs its own check, not reliance on identification done earlier in the encounter.

4.21 Falls Risk Assessed and Actively Prevented

NON-NEGOTIABLE

Every patient is assessed for fall risk on admission using a structured tool, with prevention measures implemented for anyone identified at risk, and every fall tracked as a safety indicator.

VERIFICATION QUESTIONS

  1. Is every patient assessed for fall risk on admission using a structured, validated tool?
    Not clinical impression alone — a defined scoring tool such as the Morse Fall Scale or an equivalent.
  2. Are specific prevention measures implemented for patients identified as high risk?
    A completed assessment that does not change anything about care provides no protection.
  3. Are falls tracked as a safety indicator, with each fall reviewed?
    Tracking without review misses the chance to learn from each incident.

4.22 Look-Alike, Sound-Alike Medications Are Specifically Managed

CORE

Medications with names or packaging that could be confused with another are identified on a specific list and managed with distinct safeguards — separated storage, distinct labelling, or an independent check — not treated the same as any other medication.

VERIFICATION QUESTIONS

  1. Does a specific, named list of look-alike, sound-alike medications exist for this facility's own formulary?
    Generic awareness of the concept is not the same as a specific list for what this facility stocks.
  2. Are LASA medications stored separately or distinctly labelled to prevent mix-up?
    Physical or visual separation, not reliance on staff memory alone.
  3. Is there a specific check step for LASA medications distinct from general dispensing practice?
    An additional safeguard specific to this risk, not just standard dispensing care.

4.23 Restraint and Seclusion Use Is Governed and Minimised

CORE

Physical or chemical restraint and seclusion are used only under a defined protocol, as a last resort, time-limited, monitored, and documented — never as a routine or convenience practice.

VERIFICATION QUESTIONS

  1. Is there a written protocol governing when restraint or seclusion may be used, as a last resort only?
    A specific, documented threshold, not a general judgement call left to individual staff.
  2. Is every use time-limited, monitored, and documented, with a defined review point?
    Open-ended or unmonitored use is not acceptable under any protocol.
  3. Is restraint or seclusion use reviewed to check it is not becoming routine for particular patients or situations?
    Pattern review catches drift from last-resort toward habitual use.

4.24 Nutrition and Therapeutic Diet Needs Are Actively Managed

CORE

Patients are screened for nutritional risk, therapeutic diets are correctly identified and delivered, and food handling meets basic safety standards — nutrition treated as part of clinical care, not a hospitality afterthought.

VERIFICATION QUESTIONS

  1. Is every patient screened for nutritional risk on admission?
    A specific screening step, not an assumption that nutrition will be addressed informally if it becomes relevant.
  2. Are therapeutic diets correctly identified, prescribed, and verified as delivered to the right patient?
    A diet order that does not reliably reach the correct patient provides no benefit.
  3. Does food handling meet basic safety standards, verified directly, not assumed?
    Kitchen and food service hygiene should be checked directly, with the same discipline applied as in clinical infection control.

4.25 Deteriorating Patients Are Caught Before the Crisis, Not After

NON-NEGOTIABLE

A structured early warning score is calculated from routine vital signs, tracked over time, and triggers a defined escalation response when it crosses a threshold — not left to individual clinical impression alone to notice a patient is declining.

VERIFICATION QUESTIONS

  1. Is a structured early warning score calculated from routine vital signs, not just individual readings checked in isolation?
    A composite score tracking trend, not six separate numbers each compared to a normal range independently.
  2. Is there a defined escalation response triggered when the score crosses a specific threshold?
    A specific, named response — not "someone will probably notice and do something."
  3. Is the score recalculated on a defined schedule, not only when a nurse happens to have time?
    A schedule that holds even during busy shifts is what catches deterioration in time.

4.26 Sepsis Is Recognised and Treated Within the Hour

NON-NEGOTIABLE

Staff are trained to recognise sepsis using a standardised screening approach, and a defined care bundle — including prompt antibiotics and fluid resuscitation — is initiated without delay once sepsis is suspected, not after a diagnosis is fully confirmed.

VERIFICATION QUESTIONS

  1. Is there a standardised screening approach staff use to identify possible sepsis, not informal clinical suspicion alone?
    A specific, structured screening tool, not left to individual recognition varying by experience.
  2. Does a defined care bundle begin immediately on suspicion, not after full diagnostic confirmation?
    Suspicion triggers action; waiting for certainty costs the time that matters most.
  3. Is time from suspicion to first antibiotic dose tracked as a specific, monitored metric?
    An untracked interval cannot be improved, and clinicians will not know if delays are happening.

4.27 Pressure Injury Risk Is Assessed and Actively Prevented

CORE

Every patient is assessed for pressure injury risk on admission and periodically thereafter, with a specific, documented prevention plan for at-risk patients — repositioning schedules, appropriate surfaces — not addressed only after an injury has already developed.

VERIFICATION QUESTIONS

  1. Is every patient assessed for pressure injury risk on admission using a structured tool?
    A validated risk assessment tool, not visual inspection alone.
  2. Is risk reassessed periodically during a stay, not only at the point of admission?
    Risk can change significantly as a patient's mobility or condition changes during their stay.
  3. Does a documented, specific prevention plan exist for patients identified as at-risk?
    Specific interventions — repositioning schedule, surface type — not a general awareness the patient is at risk.

4.28 VTE Risk Is Assessed Before Every Admission and Procedure

CORE

Every patient is assessed for venous thromboembolism risk at admission and before surgical procedures, with appropriate prophylaxis — pharmacological or mechanical — prescribed and administered for at-risk patients, not left as a general awareness that blood clots are a possible complication.

VERIFICATION QUESTIONS

  1. Is every patient assessed for VTE risk at admission using a structured tool?
    A specific, structured assessment, not informal judgement about which patients seem higher risk.
  2. Is risk reassessed before surgical procedures specifically, not only at general admission?
    Surgery itself changes VTE risk, and pre-procedure reassessment catches that shift.
  3. Is appropriate prophylaxis prescribed and administered for patients identified as at-risk?
    Identification without follow-through provides no protection.

4.29 Blood and Blood Products Are Verified Before Every Transfusion

NON-NEGOTIABLE

Blood and blood products are matched to the correct patient through an independent two-person verification at the bedside immediately before transfusion, with the reaction monitored throughout — not a single check at collection assumed to hold true all the way to administration.

VERIFICATION QUESTIONS

  1. Is there an independent two-person verification of blood product and patient identity immediately before transfusion, at the bedside?
    Two people, independently, at the actual point of administration — not a single check earlier in the process.
  2. Is the patient monitored for a reaction during and immediately after transfusion, on a defined schedule?
    A specific monitoring schedule, not "someone will notice if something goes wrong."
  3. Is there a defined, immediate response protocol for a suspected transfusion reaction?
    A specific, known process — not improvisation in the moment.

4.30 Handoffs Use a Structured, Verbal Process, Not Just a Written Note

NON-NEGOTIABLE

Clinical handoffs between shifts or care teams follow a structured, standardised format delivered verbally with an opportunity to ask questions — not a written note alone that the receiving clinician reads without any live exchange.

VERIFICATION QUESTIONS

  1. Do handoffs follow a structured, standardised format, not an unstructured verbal or written summary?
    A defined structure — covering the same essential elements every time, not left to individual habit.
  2. Is the handoff delivered live and verbally, with an opportunity for the receiving clinician to ask questions?
    Live exchange, not a written note read in isolation with no chance to clarify.
  3. Is the handoff process consistent across shift changes and between departments, not only within one team's habit?
    Consistency matters most exactly at the boundaries where information is most likely to be lost.

4.31 Opioid Prescribing Is Deliberately Stewarded

CORE

Opioid prescribing follows a defined stewardship approach — appropriate dose and duration, consideration of non-opioid alternatives, and monitoring for signs of diversion or misuse — led by a trained, designated person or a physician champion where no dedicated pharmacy function exists. Opioids are managed as a distinct risk, not simply as one more high-alert medication.

VERIFICATION QUESTIONS

  1. Is there a defined stewardship approach for opioid prescribing, distinct from general high-alert medication management?
    Specific to opioids — dose, duration, alternatives — not folded generically into broader medication safety.
  2. Are non-opioid alternatives considered and documented before opioid prescribing, not just theoretically available?
    Evidence of actual consideration, not an assumption that alternatives were weighed.
  3. Is there monitoring for signs of diversion or misuse, not just appropriate initial prescribing?
    Stewardship extends beyond the prescribing moment into ongoing awareness.

4.32 Pain Is Formally Assessed and Reassessed, Not Just Asked About Once

CORE

Every patient's pain is assessed using a structured tool on admission and reassessed at defined intervals, particularly after any intervention intended to address it — not asked about once informally and left unrevisited.

VERIFICATION QUESTIONS

  1. Is pain assessed using a structured tool on admission, not an informal, unstructured question?
    A specific, structured scale appropriate to the patient, not a general "how are you feeling" check.
  2. Is pain reassessed at defined intervals, particularly after any intervention intended to address it?
    Reassessment specifically tied to interventions, not just a general periodic check.
  3. Are reassessment results used to adjust the care plan, not just recorded and left unactioned?
    A reassessment that does not influence care provides no benefit over not reassessing at all.

4.33 Dignity, Respect, and Non-Discrimination Are Practised, Not Just Stated

NON-NEGOTIABLE

Every patient is treated with dignity and respect regardless of background, and care decisions are demonstrably free of discrimination based on race, religion, gender, disability, sexual orientation, or any other protected characteristic — verified through observation and patient experience, not assumed from a written policy.

VERIFICATION QUESTIONS

  1. Is there a written non-discrimination policy covering care decisions, not only administrative or employment matters?
    Specifically covering clinical care and treatment decisions, not just a general workplace policy.
  2. Can staff describe specific ways they ensure equitable treatment across different patient backgrounds?
    Concrete, specific practices, not a general assurance that discrimination does not happen here.
  3. Is there a mechanism for a patient to report perceived discriminatory treatment, distinct from a general complaint process?
    A pathway that specifically names and takes discrimination concerns seriously, not folded anonymously into general feedback.

4.34 Vulnerable Patients Get Specific Protections

NON-NEGOTIABLE

Patients who are elderly, cognitively impaired, or otherwise vulnerable to reduced capacity for self-advocacy receive specific, documented additional protections — not the same general care approach applied to every patient regardless of their actual ability to protect their own interests.

VERIFICATION QUESTIONS

  1. Is there a process to identify patients with reduced capacity for self-advocacy, not left to informal staff judgement alone?
    A specific, structured identification process, not assumed to be obvious.
  2. Do identified vulnerable patients receive specific, documented additional protections?
    Concrete, named protections — not the same general care approach applied to everyone.
  3. Is there a designated advocate or process ensuring a vulnerable patient's interests are actively represented in care decisions?
    Active representation, not an assumption that standard processes adequately protect everyone equally.

4.35 Advance Directives Are Sought, Documented, and Followed

CORE

Patients are asked about existing advance directives and offered support to create one where appropriate, with any documented directive accessible to the care team and followed — not asked once as a formality with no mechanism ensuring it influences actual care decisions.

VERIFICATION QUESTIONS

  1. Are patients asked about existing advance directives as part of standard admission practice?
    A routine, standard question, not asked inconsistently or only when a situation prompts it.
  2. Is a documented advance directive accessible to the care team at the point of an actual decision?
    Findable in the moment it matters, not filed somewhere nobody checks during an emergency.
  3. Is there evidence that documented directives influence care decisions when relevant?
    Adherence, not just documentation that exists but goes unconsulted.

4.36 The Facility Tracks Its Own Infection Rate Over Time

CORE

The facility measures and trends its own healthcare-associated infection rate as a standing indicator, reviewed regularly, and does not rely only on individual prevention bundles, such as those for surgical site infection, to show that infections are falling.

VERIFICATION QUESTIONS

  1. Does the facility measure its own healthcare-associated infection rate, not only comply with individual prevention practices?
    A tracked number specific to this facility, not an assumption that following the bundles is sufficient on its own.
  2. Is the rate trended over time and reviewed on a regular schedule, not calculated once and left unexamined?
    A single measurement does not show a trend; regular review is what reveals whether prevention practice is working.
  3. Does the facility know whether its rate is improving, worsening, or unchanged, and can it say why?
    Engagement with what the data shows, not data collected and filed without interpretation.

4.37 Medication Safety Does Not Depend on Software That Is Not Working

NON-NEGOTIABLE

Where an electronic system is used for medication safety checks — drug interactions, allergy alerts, duplicate therapy — its actual function is verified and audited, not assumed from its presence, and where records are split between paper and electronic, one is clearly designated as the record staff check first, so the two can never silently disagree about what a patient is taking.

VERIFICATION QUESTIONS

  1. If your electronic system claims to check for drug interactions, allergies, or duplicate therapy, has this been tested and confirmed to work
    not assumed from the system's marketing or original configuration? — A specific test — entering a known interacting pair and confirming an alert fires — not an assumption the feature works because it was purchased.
  2. If safety checks are not confirmed working, or do not exist, is there a specific manual backup step staff use instead?
    A defined paper checklist or verbal double-check, not an informal hope that staff will individually remember to be careful.
  3. Where records are split between paper and electronic
    common during power instability — is one specific version designated as what staff check first, avoiding the two silently disagreeing? — A named, consistent rule, not left to individual staff judgement about which version to trust in the moment.

4.38 Pharmacy Services Dispense Safely and Accountably

NON-NEGOTIABLE

Medicines are dispensed by or under the supervision of a pharmacist or an equivalently qualified person, stock is controlled, controlled substances are accounted for at every movement, and each dispensing error is recorded and reviewed.

VERIFICATION QUESTIONS

  1. Is every dispensing supervised by a pharmacist or an equivalently qualified person, and is the supervision recorded?
    Dispensing without a qualified check is where most dispensing errors start.
  2. Are stock levels, expiry and storage conditions monitored, with expired or damaged stock removed?
    Expired or unstored medicines cause harm without anyone noticing.
  3. Are controlled substances counted and accounted for at each movement, with discrepancies investigated?
    A discrepancy that is not investigated invites diversion. ————————————————————

← All ASF Health Standards

© 2026 Accréditation Sans Frontières · PHIG · Sheni Network