Standards › ASF Health Standards v10 › Standard 59
Standard 59
Outpatient Medical Specialties
Outpatient medical specialties: referrals triaged and tracked to an appointment, specialist consultations assessed and consented within the clinician scope, results communicated and missing results followed up, medicines reviewed at each visit, and recall and follow-up planned.
Every referral to a specialist clinic is triaged on receipt against a set criteria list. Urgent referrals are seen within the set time, and every referral is tracked until the patient is seen or the referral is closed.
How the surveyor verifies this criterion
Sample. Review the referral log for the clinic for the last 3 months, including every urgent referral and a random sample of routine referrals.
1. Every referral is triaged on receipt against the criteria list.
Method. Check each sampled referral for the triage entry and its date against the receipt date.
Evidence to show. Referral criteria and referral tracking (PHC-SOP-003, existing, reused); referral tracking register (PHC-REG-002, existing, reused).
Pass when. Every sampled referral has a triage entry on the day of receipt.
2. Urgent referrals are seen within the set time.
Method. Check the appointment date against the set time for each urgent referral in the sample.
Evidence to show. Urgent referral pathway (GYN-POL-001, existing, reused, for gynaecology); urgent eye and ear referral (OPT-POL-003, existing, reused).
Pass when. Every urgent referral in the sample was seen within the set time.
3. Every referral is tracked until the patient is seen or the referral is closed.
Method. Check the register for each sampled referral for a closed status.
Evidence to show. Referral tracking register (PHC-REG-002, existing, reused).
Pass when. Every sampled referral has a recorded outcome or closure.
Immediate fail (any one means the criterion is not met)
- An urgent referral sits in a tray for six weeks, and the patient presents with a delayed diagnosis.
Documents
No documents yet.
E-learning
References
- World Health Organization. Framework on integrated people-centred health services. Geneva: WHO; 2016.
Each specialist consultation begins with a documented assessment and informed consent. The clinician is verified as qualified and within scope for the service delivered, and the outcome is sent to the referring clinician.
How the surveyor verifies this criterion
Sample. Review the consultation records and the clinician scope register for a sample of specialist consultations in the last 6 months.
1. Each consultation begins with a documented assessment.
Method. Check each sampled consultation for the assessment entries.
Evidence to show. Specialist consultation procedure (OMS-SOP-001); specialist consultation record (OMS-FRM-001).
Pass when. Every sampled consultation has the assessment recorded.
2. Informed consent is recorded for each consultation that involves a procedure or treatment.
Method. Check each sampled consultation involving a procedure for the consent record.
Evidence to show. Informed consent before significant care (CON-SOP-001, existing, reused); consent record (CON-FRM-001, existing, reused).
Pass when. Every sampled procedure has consent recorded.
3. The clinician is qualified and within scope for the service.
Method. Compare the clinician for each sampled consultation with the scope register.
Evidence to show. Clinician qualification and scope register (SPM-REG-002, existing, reused).
Pass when. Every sampled clinician is within scope for the service delivered.
4. The outcome is sent to the referring clinician.
Method. Check each sampled consultation for the letter sent to the referrer.
Evidence to show. Specialist consultation record (OMS-FRM-001).
Pass when. Every sampled consultation has the outcome sent to the referrer.
Immediate fail (any one means the criterion is not met)
- A clinician performs a procedure outside the scope on their register, and the patient suffers a complication.
Documents
E-learning
References
- Council for International Organizations of Medical Sciences. International Ethical Guidelines for Health-related Research Involving Humans. Geneva: CIOMS; 2016.
Results of tests done in the clinic are communicated to the patient and the referring clinician. Critical results are reported at once, and results not received within the set time are chased and recorded.
How the surveyor verifies this criterion
Sample. Review the results log and the missing results records for the clinic for the last 6 months, including every critical result.
1. Results are communicated to the patient and the referring clinician.
Method. Check each sampled result for the communication entries.
Evidence to show. Missing results follow-up (SPC-SOP-003, existing, reused).
Pass when. Every sampled result has communication to the patient and referrer recorded.
2. Critical results are reported at once.
Method. Check each critical result for the time between result and report.
Evidence to show. Critical result reporting (HOS-SOP-009, existing, reused); critical result log (HOS-REG-002, existing, reused).
Pass when. Every critical result in the sample was reported at once.
3. Results not received within the set time are chased and recorded.
Method. Check each outstanding result in the sample for the chase entry.
Evidence to show. Missing results follow-up (SPC-SOP-003, existing, reused).
Pass when. Every outstanding result was chased within the set time and the chase recorded.
Immediate fail (any one means the criterion is not met)
- A critical blood result is not reported, and the patient is not told for ten days.
Documents
No documents yet.
E-learning
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705
Medicines are reviewed and reconciled at each visit, with changes recorded. Patients who need an interpreter are offered one, and its use is recorded.
How the surveyor verifies this criterion
Sample. Review the visit records and interpreter use records for a sample of patients in the last 6 months.
1. Medicines are reviewed and reconciled at each visit, and changes are recorded.
Method. Check each sampled visit for the review and any change recorded.
Evidence to show. Outpatient medicines review record (OMS-FRM-002); medicines reconciliation (HOS-SOP-007, existing, reused).
Pass when. Every sampled visit has the medicines review recorded.
2. Patients who need an interpreter are offered one.
Method. Check each sampled patient with a language need for the offer recorded.
Evidence to show. Language access and interpreters (MTR-POL-002, existing, reused).
Pass when. Every sampled patient with a language need was offered an interpreter.
3. Interpreter use is recorded.
Method. Check each sampled interpreter use for the record.
Evidence to show. Interpreter use record (MTR-FRM-003, existing, reused).
Pass when. Every sampled interpreter use is recorded.
Immediate fail (any one means the criterion is not met)
- A patient who does not speak the language is given instructions for a new medicine with no interpreter, and takes the wrong dose.
Documents
E-learning
References
- World Health Organization. Medication Without Harm: Global Patient Safety Challenge on Medication Safety. Geneva: WHO; 2017.
Each patient has a follow-up or recall plan set at the visit, with the date recorded. Patients who miss a planned review are contacted and the outcome is recorded.
How the surveyor verifies this criterion
Sample. Review the follow-up and recall records for every outpatient in the last 6 months, including patients who missed a review.
1. Each patient has a follow-up or recall plan with a date recorded at the visit.
Method. Check each sampled visit for a recorded follow-up or recall date.
Evidence to show. Outpatient recall and follow-up register (OMS-REG-001); recall test record (PHA-FRM-002, existing, reused); screening recall and result register (GYN-REG-001, existing, reused).
Pass when. Every sampled visit has a follow-up or recall date recorded.
2. Patients who miss a planned review are contacted.
Method. Check each sampled missed review for the contact entry.
Evidence to show. Post-discharge contact register (AFT-REG-001, existing, reused); post-discharge follow-up register (HOS-REG-003, existing, reused).
Pass when. Every sampled missed review has a recorded contact.
3. The outcome of each contact is recorded.
Method. Check each contact entry for the outcome.
Evidence to show. Outpatient recall and follow-up register (OMS-REG-001).
Pass when. Every contact has a recorded outcome.
Immediate fail (any one means the criterion is not met)
- A patient with a diabetes medicine change misses the review, is not contacted, and presents with hyperglycaemia.
Documents
E-learning
References
- World Health Organization. Framework on integrated people-centred health services. Geneva: WHO; 2016.
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