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Standards Map

Resources › Standards Map

A map of how the standards fit together: each standard, its criteria, and the documents that support each criterion. Click any item to go deeper.

Standard 1: Foundation: Universal Base

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1.1 Patient Identified at Every Point of Contact

Standard operating procedures (SOPs): ID-SOP-001

Forms: ID-FRM-001

1.2 Hand Hygiene at the Point of Care

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1.3 Informed Consent Before Significant Care

Standard operating procedures (SOPs): CON-SOP-001

Forms: CON-FRM-001

1.4 Falls Are Assessed and Prevented

Standard operating procedures (SOPs): PSF-SOP-001

Guidelines: PSF-GDL-001

Forms: PSF-FRM-001, PSF-FRM-002

1.5 Non-Discrimination in Access to Care

Forms: CON-FRM-002

Policies: CON-POL-002

1.6 Emergency Access and Fire Safety

Standard operating procedures (SOPs): EMG-SOP-001

Forms: EMG-FRM-001, EMG-FRM-002

1.7 Patients Know Their Rights

Policies: CON-POL-001

1.8 Staff Are Qualified, Verified and Current

Standard operating procedures (SOPs): STF-SOP-001

Forms: STF-FRM-001

1.9 Medicines Are Prescribed, Stored and Given Safely

Standard operating procedures (SOPs): PHM-SOP-001

Forms: PHM-FRM-001, PHM-FRM-002

1.10 Sharps and Clinical Waste Are Handled Safely

Standard operating procedures (SOPs): WST-SOP-001

Forms: WST-FRM-001

1.11 Records Are Complete and Private, and Incidents and Complaints Are Acted On

Forms: REC-FRM-001, REC-FRM-002

Policies: INC-POL-001, INC-POL-002, REC-POL-001

1.12 Patients Learn, Decide and Shape the Service

Policies: CON-POL-003, INC-POL-002

1.13 Service Scope Is Declared

Forms: GOV-FRM-001

Standard 2A: Governance and Safety Culture

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2A.1 The Board Is Accountable

Standard operating procedures (SOPs): GOV-SOP-001

Forms: GOV-FRM-003

Registers and logs: GOV-REG-001

Policies: GOV-POL-001

2A.2 There Is a Written Strategic Plan

Plans and templates: GOV-PLN-001

Policies: GOV-POL-002

2A.3 Policy Gets Followed

Forms: GOV-FRM-002

Registers and logs: GOV-REG-002

Plans and templates: GOV-PLN-002

Policies: GOV-POL-003

2A.4 Patient Data Is Kept Secure

Standard operating procedures (SOPs): DIG-SOP-001

Forms: DIG-FRM-001

Policies: DIG-POL-001

2A.5 Records Are Kept Exactly as Long as Required

Registers and logs: REC-FRM-003

2A.6 Serious Incidents Get Properly Investigated

Standard operating procedures (SOPs): INC-SOP-001

Forms: INC-FRM-001

Registers and logs: INC-REG-001

2A.7 Safety Culture Is Measured

Standard operating procedures (SOPs): QUA-SOP-001

Forms: QUA-FRM-001

Registers and logs: QUA-REG-001

2A.8 Patient Experience Is Measured Continuously, Not Only After Discharge

Standard operating procedures (SOPs): CON-SOP-002

Forms: CON-FRM-004

Registers and logs: QUA-REG-002

2A.9 An Ethics Consultation Process Exists

Standard operating procedures (SOPs): GOV-SOP-002

Registers and logs: GOV-REG-003

Policies: GOV-POL-004

2A.10 Patients and Families Have a Voice in Governance

Registers and logs: GOV-REG-004

Policies: GOV-POL-005

Standard 2B: Facility, Environment and Equipment

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2B.1 Reception Desk Accessibility

Standard operating procedures (SOPs): ENV-SOP-001

Forms: ENV-FRM-001

2B.2 Waiting and Queue Time Is Actively Managed

Standard operating procedures (SOPs): ACC-SOP-001

Forms: ACC-FRM-001

Registers and logs: ACC-REG-001

2B.3 Water Supply Is Safe and Monitored

Standard operating procedures (SOPs): WAT-SOP-001

Forms: WAT-FRM-001

Plans and templates: WAT-PLN-001

2B.4 Medical Equipment Is Maintained on Schedule

Standard operating procedures (SOPs): EQP-SOP-001

Forms: EQP-FRM-001

Registers and logs: EQP-REG-001

2B.5 Shared Spaces Are Clean

Standard operating procedures (SOPs): ENV-SOP-002

Forms: ENV-FRM-002

2B.6 Facility Risks Are Tracked in One Integrated Register

Standard operating procedures (SOPs): FAC-SOP-001

Registers and logs: FAC-REG-001

2B.7 An Environmental Sustainability Programme Is Active

Forms: ENV-FRM-003

Plans and templates: ENV-PLN-001

2B.8 Facility Signage Is Complete Throughout the Building

Standard operating procedures (SOPs): ENV-SOP-003

Forms: ENV-FRM-005

2B.9 Fault Prevention Is Planned, Not Only Repaired

Standard operating procedures (SOPs): FAC-SOP-002

Registers and logs: FAC-REG-002

Plans and templates: FAC-PLN-001

2B.10 Endoscopy Equipment Is Safe to Use and Properly Reprocessed

Standard operating procedures (SOPs): EQP-SOP-002

Registers and logs: EQP-REG-002

Standard 2C: Sustainability

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2C.1 Environmental Impact Is Reviewed at Strategic Level

Standard operating procedures (SOPs): ENV-SOP-004

Forms: ENV-FRM-006

2C.2 Staff and Patients Are Informed of Sustainability Goals

Forms: ENV-FRM-007

Registers and logs: ENV-REG-001

Plans and templates: ENV-PLN-002

2C.3 Sustainability Progress Is Reported to Governance

Standard operating procedures (SOPs): ENV-SOP-005

2C.4 Procurement Considers Responsible Stewardship of Resources

Standard operating procedures (SOPs): PRC-SOP-001

Forms: PRC-FRM-001

Policies: PRC-POL-001

2C.5 Energy Use Is Monitored, With a Move Toward Renewable Sources

Standard operating procedures (SOPs): ENV-SOP-006

Forms: ENV-FRM-008

Plans and templates: ENV-PLN-003

2C.6 A Carbon Footprint Baseline Exists

Standard operating procedures (SOPs): ENV-SOP-007

Forms: ENV-FRM-009

2C.7 The Facility Plans for Environmental and Climate Resilience

Standard operating procedures (SOPs): FAC-SOP-003

Forms: FAC-FRM-003

Plans and templates: FAC-PLN-002

Standard 2D: Digital Care and AI

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2D.1 Digital Care Systems Follow an Assessment and Management Process

Standard operating procedures (SOPs): DIG-SOP-002

Forms: DIG-FRM-002

2D.2 Digital Care Never Disadvantages a Patient Who Cannot Use It

Standard operating procedures (SOPs): DIG-SOP-003

Forms: DIG-FRM-003

2D.3 Technical Expertise Supports Digital Care Systems

Forms: DIG-FRM-004

Plans and templates: DIG-PLN-001

2D.4 AI Systems Are Introduced in Line With WHO AI Governance Guidance

Forms: AI-FRM-001

Policies: AI-POL-001

2D.5 AI Systems Are Monitored for Unintended Consequences

Standard operating procedures (SOPs): AI-SOP-001

Registers and logs: AI-REG-001

2D.6 Staff Are Consulted Before an AI System Is Introduced

Standard operating procedures (SOPs): AI-SOP-002

Forms: AI-FRM-002

2D.7 Accountability for AI-Assisted Care Is Explicitly Defined

Policies: AI-POL-002

2D.8 Patients Are Informed When Their Care Involves AI

Standard operating procedures (SOPs): AI-SOP-003

Forms: AI-FRM-003

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