Accréditation Sans Frontières · ASF Health Standards 9.0
Standard 5 · Safety & Emergency Preparedness
6 criteria · base standard
Base standard. 6 criteria, of which 6 non-negotiable. Each criterion is numbered 5.Y, with its classification and verification questions.
Criteria
- 5.1 Triage Sorts Patients by Urgency (NON-NEGOTIABLE)
- 5.2 Resuscitation Equipment Is Ready Right Now (NON-NEGOTIABLE)
- 5.3 A Disaster Response Plan Exists and Is Rehearsed (NON-NEGOTIABLE)
- 5.4 Fire Safety Is Tested and Drilled (NON-NEGOTIABLE)
- 5.5 Workplace Violence Is Prevented, Not Just Responded To (NON-NEGOTIABLE)
- 5.6 Internal Emergency Alerts Are Clear, Consistent, and Trained (NON-NEGOTIABLE)
5.1 Triage Sorts Patients by Urgency
NON-NEGOTIABLE
A structured triage system using a validated, internationally recognised urgency scale — such as the Manchester Triage System, the Canadian Triage and Acuity Scale, or an equivalent validated tool — prioritises patients by clinical urgency, used consistently for every arriving patient, not applied selectively based on how busy the department is.
VERIFICATION QUESTIONS
- Is a validated, internationally recognised triage scale used, not an informal or home-grown urgency judgement?
A named, validated tool — Manchester Triage System or equivalent — not individual staff discretion alone. - Does every triage nurse or staff member use the same scale consistently, not a personal variation of it?
Consistency across staff is what makes the scale meaningful as a system, not just a suggestion. - Is the assigned urgency category documented for every patient, with the maximum wait time it implies?
A category without a documented, implied wait time does not translate into an actual commitment to the patient.
5.2 Resuscitation Equipment Is Ready Right Now
NON-NEGOTIABLE
Resuscitation equipment is checked every shift, fully stocked and functional, and staff holding life support certification are current, not overdue for recertification.
VERIFICATION QUESTIONS
- Is resuscitation equipment checked every shift, with a documented record?
Not checked "regularly" — checked every single shift, verifiably. - Is all equipment found fully stocked and functional at each check, with gaps immediately addressed?
A check that finds gaps but does not trigger immediate resupply provides only partial protection. - Are all relevant staff current on life support certification, not overdue?
A lapsed certification discovered only during an emergency is a preventable failure.
5.3 A Disaster Response Plan Exists and Is Rehearsed
NON-NEGOTIABLE
A mass casualty and disaster response plan exists and has been practised through a drill, not written once and filed without ever being tested.
VERIFICATION QUESTIONS
- Does a documented mass casualty and disaster response plan exist?
Specific to mass casualty and disaster scenarios, not a general emergency policy. - Has the plan been practised through a drill, not just written and filed?
An unrehearsed plan's real-world gaps are unknown until an actual disaster reveals them. - Were lessons from the drill documented and used to update the plan?
A drill that does not feed back into plan improvement misses much of its value.
5.4 Fire Safety Is Tested and Drilled
NON-NEGOTIABLE
Fire safety equipment is tested on schedule and an evacuation drill has been run with staff participation, not merely documented as a policy requirement.
VERIFICATION QUESTIONS
- Is fire safety equipment tested on a defined schedule, with records kept?
Extinguishers, alarms, and sprinkler systems specifically, not a general assumption of functionality. - Has an evacuation drill been run, with staff and patient-area participation?
A tabletop discussion of the evacuation plan is not the same as a physical drill. - Are evacuation routes kept clear, not obstructed in practice?
A route that is clear on paper but blocked by stored equipment fails when it matters.
5.5 Workplace Violence Is Prevented, Not Just Responded To
NON-NEGOTIABLE
A specific workplace violence prevention policy covers violence from patients, visitors, and staff-on-staff, with preventive measures in place — not a policy that only describes what happens after an incident occurs.
VERIFICATION QUESTIONS
- Is there a written workplace violence policy covering violence from patients and visitors, and separately, staff-on-staff violence?
Both categories explicitly, not just one assumed to cover the other. - Was the policy developed in consultation with staff, not written and issued without their input?
Consultation matters because staff experience is what makes a prevention policy relevant. - Are preventive measures in place
not only a response plan for after an incident occurs? — Prevention, not just reaction — physical measures, staffing considerations, early warning signs training.
5.6 Internal Emergency Alerts Are Clear, Consistent, and Trained
NON-NEGOTIABLE
The facility has a clearly defined, documented internal emergency alert system — whether colour-coded or plain-language — covering the significant emergency types relevant to this facility, with every staff member trained and able to respond correctly, rather than relying on staff to infer meaning from context.
VERIFICATION QUESTIONS
- Does the facility have a clearly documented internal emergency alert system, whether colour-coded or plain-language?
A specific, written system — not an assumption that staff will understand codes from general experience elsewhere. - Are all staff, including new hires and temporary or agency staff, trained on this specific facility's system?
Facility-specific training, not reliance on what a code meant at a previous workplace. - Can staff correctly state what happens for each alert type used at this facility, not just recognise that an alert occurred?
Understanding the required response, not just recognising that something is happening. ————————————————————