Standards 2-6: Governance and Safety Culture (Version 11)

Why it matters. A facility with no clearly accountable governing body has no one answerable for safety and quality when things go wrong. Named members with documented authority make that accountability real.

Sample. Review the governing body’s records for the last 12 months, and its terms of reference.

1. A governing body with named members and defined terms exists.

Method. Check the terms of reference and the membership register for named members and their terms of office.

Evidence to show. GOV-POL-001 Governing Body Terms of Reference; GOV-REG-001 Register of Governing Body Members.

Pass when. Every member is named and has a defined term.

2. The body meets on a fixed schedule, with minutes kept.

Method. Compare the meeting dates in the minutes with the schedule set in the procedure.

Evidence to show. GOV-FRM-003 Governing Body Minutes Template, completed for each meeting.

Pass when. Meetings take place on the scheduled dates, and minutes exist for each one.

3. Quality, safety and financial oversight are assigned to the board.

Method. Read the minutes for a quality and safety review at each meeting, and check that clinical governance and financial stewardship are named board responsibilities.

Evidence to show. GOV-SOP-001 Governing Body Meetings and Decisions on Safety and Quality; minutes.

Pass when. Each meeting records a quality and safety review, and both responsibilities are named in the procedure.

Immediate fail (any one means the criterion is not met)

• The governing body does not exist, or has no minutes for the last 12 months.

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Why it matters. A facility without a written plan drifts, and its resources follow whichever problem is loudest that week. A written plan with a mission, values and code of conduct sets the direction that staff and the board can be held to.

Sample. Review the plan and the code of conduct currently in force, and the decisions made in the last year.

1. A written strategic plan covers at least several years.

Method. Check the plan’s period, its approval record and its mission statement.

Evidence to show. GOV-PLN-001 Strategic Plan (template and approval).

Pass when. The plan is approved, covers a multi-year period and states a mission.

2. A resourcing decision can be traced to the plan.

Method. Select one budget or staffing decision from the last year and trace its link to a plan objective.

Evidence to show. The budget or staffing decision record, and the plan.

Pass when. The decision refers to a plan objective.

3. Values and a code of conduct guide staff behaviour.

Method. Ask staff to describe the code of conduct, and check that it is separate from the mission statement.

Evidence to show. GOV-POL-002 Code of Conduct for Staff.

Pass when. The code of conduct is approved, separate from the mission, and staff can describe its main points.

Immediate fail (any one means the criterion is not met)

• The facility has no written strategic plan, or no code of conduct for staff.

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Why it matters. Many facilities have a complete set of policies that nobody follows. A policy that staff cannot explain in practice is a document, not a control.

Sample. Select three policies at random and check them against practice in the last 12 months.

1. Staff can describe how a named policy is applied.

Method. Ask staff in two areas to describe how one selected policy is applied in their daily work.

Evidence to show. GOV-FRM-002 Policy Application Audit Form, completed for each selected policy.

Pass when. Staff describe the policy as it is written.

2. Adherence is checked and gaps have a defined response.

Method. Read the audit records and check that each gap has an action recorded.

Evidence to show. GOV-REG-002 Policy Register; GOV-FRM-002 audit records.

Pass when. Every gap found has a recorded action.

3. The quality improvement plan is complete, authorised and reviewed.

Method. Check the plan for all five areas, its named owners and indicators, and its approval and review dates.

Evidence to show. GOV-PLN-002 Quality Improvement Plan; GOV-POL-003 Policy Development, Approval, Review and Application.

Pass when. The plan covers all areas, each has a named owner and an indicator, and approval and review are dated.

Immediate fail (any one means the criterion is not met)

• A policy is in use with no adherence check, and no response when a policy-practice gap is found.

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Why it matters. Patient health information is sensitive, and a breach can harm patients and families. Defined access controls and a breach response plan keep it protected, even in a temporary setting.

Sample. Review the access controls and the breach response plan currently in force.

1. Access to patient data is restricted by role.

Method. Check the access list against staff roles for a sample of systems and paper records.

Evidence to show. DIG-POL-001 Information Security and Access Control Policy.

Pass when. Every person with access has a role that needs it.

2. A breach response plan exists and is actionable.

Method. Read the procedure and check that it names the steps, the responsible person and the reporting route.

Evidence to show. DIG-SOP-001 Patient Data Breach Response Procedure.

Pass when. The procedure names who acts, what they do and how it is reported.

3. Access controls and the breach plan have been tested.

Method. Check the date and result of the most recent test or review.

Evidence to show. DIG-FRM-001 Breach Response Test Record.

Pass when. A test or review is recorded within the last 12 months, with actions closed.

Immediate fail (any one means the criterion is not met)

• Patient records can be accessed by staff with no role-based need, and no breach response plan exists.

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Why it matters. Keeping records forever is costly and risky, and destroying them too early can break the law and remove evidence a patient needs. A retention policy sets the period for each record type, and the disposal is recorded.

Sample. Review the retention policy and the disposal records for the last 12 months.

1. A written retention policy sets periods for each record type.

Method. Check that the policy lists each record type with its retention period.

Evidence to show. The retention policy and the record register.

Pass when. Each record type has a stated period.

2. The periods match the national requirement.

Method. Compare the periods with the legal requirement for the country where the facility operates.

Evidence to show. The national requirement cited in the policy.

Pass when. Each period is at least the national requirement.

3. Disposal is secure and documented.

Method. Select disposal records and check the date, method and authoriser.

Evidence to show. REC-FRM-003 Records Disposal Record.

Pass when. Each disposal is recorded with its date, method and authoriser.

Immediate fail (any one means the criterion is not met)

• Records are disposed of with no retention policy, or are destroyed before the retention period ends.

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Why it matters. Root cause analysis finds why an incident happened, not who was involved. A tracked action plan that is followed through is what makes the investigation worth doing.

Sample. Select every serious incident from the last 12 months.

1. A structured root cause analysis is used.

Method. Read the analysis for each serious incident and check that it follows the procedure.

Evidence to show. INC-SOP-001 Root Cause Analysis of Serious Incidents; INC-FRM-001 Root Cause Analysis Record.

Pass when. Each analysis follows the procedure and identifies root causes, not only the immediate event.

2. The analysis produces a tracked action plan.

Method. Check each action in the tracker for an owner, a date and a status.

Evidence to show. INC-REG-001 Incident Action Tracker.

Pass when. Every action has an owner and a date.

3. Actions are followed through to completion.

Method. Check the status of each action against its due date.

Evidence to show. INC-REG-001 Incident Action Tracker.

Pass when. Every action is closed or has a recorded reason for the delay.

Immediate fail (any one means the criterion is not met)

• A serious incident is closed with no root cause analysis, or its action plan is left open with no owner.

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Why it matters. Staff who are afraid to raise a concern will stay silent about the mistake that harms a patient. A validated survey, repeated and acted on, shows whether they feel able to speak up.

Sample. Review the survey records and action plans for the last 12 months.

1. A validated safety culture survey is used.

Method. Check the survey instrument and the procedure for its use.

Evidence to show. QUA-FRM-001 Safety Culture Survey (template); QUA-SOP-001 Safety Culture Survey Procedure.

Pass when. The instrument is a recognised, validated tool and the procedure is approved.

2. The survey runs on a defined schedule.

Method. Compare the survey dates with the schedule in the procedure.

Evidence to show. Survey records held under QUA-SOP-001.

Pass when. Surveys run on the scheduled dates.

3. Results are reviewed and acted on.

Method. Check the action register for each result that needed follow-up.

Evidence to show. QUA-REG-001 Safety Culture Action Plan Register.

Pass when. Each result has a reviewed action, and follow-up is visible to staff.

Immediate fail (any one means the criterion is not met)

• No safety culture survey has been conducted in the last 12 months.

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Why it matters. Patients who ask only after they leave may not say what went wrong during their stay. Feedback gathered during care, while there is still time to act, improves the care the patient is actually getting.

Sample. Review the feedback collected in the last quarter.

1. Feedback is collected during the stay.

Method. Check that the structured feedback form is used during the stay, not only after discharge.

Evidence to show. CON-FRM-004 Structured In-Stay Feedback Form; CON-SOP-002 In-Stay Patient Experience Feedback Procedure.

Pass when. Forms are completed during the stay.

2. Feedback is collected broadly.

Method. Compare the number of forms with the number of patients in the period, and check that patients who did not volunteer feedback were asked.

Evidence to show. CON-FRM-004 forms.

Pass when. Feedback is sought from patients who did not volunteer it.

3. Feedback is used to improve care.

Method. Read the quarterly summary and check for at least one improvement made from it.

Evidence to show. QUA-REG-002 Patient Feedback Summary (quarterly).

Pass when. The quarterly summary records a resulting improvement.

Immediate fail (any one means the criterion is not met)

• Patient experience is measured only after discharge, with no feedback during the stay.

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Why it matters. Clinical staff sometimes face decisions about care that are hard to make alone, such as when treatment should stop. A usable ethics consultation route gives them somewhere to go before a poor decision is made.

Sample. Review the consultation log for the last 12 months.

1. An ethics consultation process is in place.

Method. Check the policy and the terms of reference for the committee, named resource or external arrangement.

Evidence to show. GOV-POL-004 Clinical Ethics Consultation Policy and Terms of Reference.

Pass when. The policy names a route that staff can use.

2. Staff know how to access it.

Method. Ask staff how they would request an ethics consultation.

Evidence to show. GOV-SOP-002 Ethics Consultation Procedure.

Pass when. Staff describe the route correctly.

3. The process has been used.

Method. Check the log for any consultation in the last 12 months.

Evidence to show. GOV-REG-003 Ethics Consultation Log.

Pass when. At least one consultation is recorded, or the reason none was needed is recorded.

Immediate fail (any one means the criterion is not met)

• No ethics consultation route exists, or it has never been used.

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Why it matters. A service designed without the people who use it misses what matters to them. A patient or family representative in governance brings the view from outside the staff room.

Sample. Review the attendance register and minutes for the last 12 months.

1. A patient or family representative has a defined role.

Method. Check the role description in the policy.

Evidence to show. GOV-POL-005 Patient and Family Representative Role in Governance.

Pass when. The role is written, with duties in governance or quality review.

2. The representative takes part in discussion.

Method. Check the attendance register and the minutes for their contributions.

Evidence to show. GOV-REG-004 Attendance Register (governance meetings); minutes.

Pass when. The representative attends and contributes, not only observes.

3. Input has changed a decision.

Method. Ask for one recorded decision where patient or family input shaped the outcome.

Evidence to show. Minutes showing the decision.

Pass when. At least one decision is traceable to patient or family input.

Immediate fail (any one means the criterion is not met)

• No patient or family representative takes part in quality review or governance discussion.

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Why it matters. A patient who uses a wheelchair cannot register if the reception counter is too high to reach or speak across. A facility that cannot be used by every patient fails the basic test of access.

Sample. Check every reception and registration point on the facility’s main routes.

1. At least one point is at a usable height.

Method. Measure the counter height at the accessible point.

Evidence to show. ENV-FRM-001 Accessibility Check Record (reception).

Pass when. At least one counter is at a height a wheelchair user can use.

2. A wheelchair user can communicate at eye level.

Method. Check that the accessible point has a space where a seated person can be served face to face.

Evidence to show. ENV-FRM-001 Accessibility Check Record (reception).

Pass when. Communication at eye level is possible at the accessible point.

3. The lower section stays clear.

Method. Check the lower section on the day of the visit and on a second unannounced check.

Evidence to show. ENV-SOP-001 Accessible Reception and Registration Points.

Pass when. The lower section is clear on both checks.

Immediate fail (any one means the criterion is not met)

• No reception or registration point can be used by a wheelchair user.

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Why it matters. Long, unexplained waits drive patients away and hide problems. A defined queue, honest wait information and a check on waiting patients keep the flow safe and fair.

Sample. Review the queue log and wait-time reviews for the last month.

1. A defined queue system is in use.

Method. Check the queue log for registration, triage and ambulatory waiting.

Evidence to show. ACC-FRM-001 Queue Log; ACC-SOP-001 Queue and Wait-Time Management.

Pass when. A queue system is used in each of the three areas.

2. Wait-time information is shared with patients.

Method. Check that wait-time information is displayed or given to waiting patients.

Evidence to show. ACC-REG-001 Monthly Wait-Time Review.

Pass when. Information is visible or communicated during the wait.

3. Changes in condition are noticed while patients wait.

Method. Check the record of re-assessment for patients who waited longer than the set time.

Evidence to show. ACC-FRM-001 Queue Log, with re-assessment entries.

Pass when. Each long-waiting patient has a recorded re-assessment.

Immediate fail (any one means the criterion is not met)

• Patients wait with no queue system, and a waiting patient who deteriorates is not noticed.

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Why it matters. Water supply in a field setting is often the first thing to fail and the most important for health. Testing it on a schedule, with a plan for when supply stops, prevents disease outbreaks.

Sample. Review the water test records for the last 12 months.

1. Water quality is tested on a defined schedule.

Method. Compare the test dates with the schedule in the procedure.

Evidence to show. WAT-FRM-001 Water Test Record; WAT-SOP-001 Water Quality Testing and Safety.

Pass when. Tests are recorded on the scheduled dates.

2. A contingency plan exists for supply interruption.

Method. Read the plan and check that it names the alternative supply and the responsible person.

Evidence to show. WAT-PLN-001 Water Interruption Contingency Plan.

Pass when. The plan is approved and names both.

3. Results are reviewed and acted on.

Method. Check each out-of-range result for a recorded action.

Evidence to show. WAT-FRM-001 Water Test Record, with actions.

Pass when. Each out-of-range result has a recorded action.

Immediate fail (any one means the criterion is not met)

• Water is used for patients with no testing on record, or a supply failure has no contingency plan.

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Why it matters. Clinical equipment that is faulty and still in use causes injury. A maintenance schedule and removal of faulty items prevent it.

Sample. Select the clinical equipment in two clinical areas and check its service records.

1. A maintenance schedule covers all clinical equipment.

Method. Check the inventory against the maintenance schedule.

Evidence to show. EQP-REG-001 Equipment Inventory and Service Log.

Pass when. Every item on the inventory has a scheduled service.

2. Faulty equipment is taken out of use.

Method. Find any item marked faulty and check that it carries an out-of-use tag and is not in service.

Evidence to show. EQP-FRM-001 Out-of-Use Tag Record.

Pass when. Every faulty item is tagged out of use.

3. A named person runs the programme.

Method. Check the procedure for the named role responsible for maintenance.

Evidence to show. EQP-SOP-001 Medical Equipment Maintenance and Removal from Use.

Pass when. A named role is responsible, and the post-holder is known to staff.

Immediate fail (any one means the criterion is not met)

• Faulty clinical equipment is kept in use with no out-of-use tag.

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Why it matters. Shared clinical and waiting areas are where infection spreads from one patient to the next. Cleaning on a documented schedule, checked by more than a look, is what keeps those areas safe.

Sample. Review the cleaning records and the audit results for the last 3 months.

1. A cleaning schedule exists and is recorded.

Method. Compare the records with the schedule for each shared space.

Evidence to show. ENV-SOP-002 Cleaning of Shared Clinical and Waiting Areas.

Pass when. Each scheduled clean is recorded.

2. Cleaning is verified beyond a visual check.

Method. Check the audit records for a defined inspection process.

Evidence to show. ENV-FRM-002 Cleanliness Audit Record.

Pass when. Audits follow the defined process and are recorded.

3. High-touch surfaces are included.

Method. Check that high-touch surfaces are named in the schedule and in the audit.

Evidence to show. ENV-SOP-002 and ENV-FRM-002.

Pass when. High-touch surfaces are named and audited.

Immediate fail (any one means the criterion is not met)

• Shared spaces have no cleaning schedule, or no records for the last 3 months.

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Why it matters. Facility risks tracked on separate lists, one for water, one for fire, one for equipment, are seen by different people and can be missed. One integrated register shows the whole picture to the people who must act.

Sample. Review the risk register and its review records for the last 12 months.

1. Water, fire and equipment data feed one register.

Method. Check that the register contains entries from each of the three sources.

Evidence to show. FAC-REG-001 Integrated Facility Risk Register.

Pass when. Entries from all three sources are in one register.

2. Leadership reviews the register on a schedule.

Method. Check the dates and attendees of the leadership reviews.

Evidence to show. FAC-SOP-001 Facility Risk Management Procedure.

Pass when. The register is reviewed on the scheduled dates by leadership.

3. Risks are prioritised.

Method. Check that each risk has a priority rating.

Evidence to show. FAC-REG-001 Integrated Facility Risk Register.

Pass when. Every risk has a priority.

Immediate fail (any one means the criterion is not met)

• No integrated risk register exists, and water, fire and equipment risks are held in untracked lists.

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Why it matters. In an emergency, people must find the exit within seconds, and patients who cannot read a sign easily must still be guided. Clear, complete, consistent signage throughout the building is part of the emergency plan.

Sample. Walk every floor and check the signage on the evacuation routes and on department doors.

1. Evacuation routes are signed throughout.

Method. Walk each floor and check every evacuation route and exit.

Evidence to show. ENV-FRM-005 Signage Survey and Quarterly Check.

Pass when. Routes and exits are signed on every floor.

2. Restrooms and department doors are labelled consistently.

Method. Check the labels against the signage standard.

Evidence to show. ENV-SOP-003 Facility Signage Standard.

Pass when. Labels match the standard.

3. Signage is checked for damage and obstruction.

Method. Check the quarterly survey record for the last quarter.

Evidence to show. ENV-FRM-005 Signage Survey and Quarterly Check.

Pass when. The quarterly check is recorded, and defects have actions.

Immediate fail (any one means the criterion is not met)

• Evacuation routes or emergency exits are unsigned on any floor.

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Planned course: Facility signage. New course planned.

Why it matters. Power, water, medical gases and ventilation fail when they are only repaired after breaking. A tested schedule and analysis of failures prevent most of them.

Sample. Select every critical service and every failure recorded in the last 12 months.

1. Each critical service has an owner and a back-up.

Method. Check the plan for each service: power, water, medical gases, ventilation and clinical information systems.

Evidence to show. FAC-PLN-001 Critical Services Testing and Back-up Plan.

Pass when. Each service has a named owner and a documented back-up.

2. Critical services are tested on a schedule.

Method. Compare the test records with the schedule.

Evidence to show. FAC-FRM-003 Continuity Test Record, if held; FAC-PLN-001.

Pass when. Tests are recorded on the scheduled dates.

3. Failures are analysed and followed by a change.

Method. Read each failure entry for an analysis and a preventive change.

Evidence to show. FAC-REG-002 Failure Log; FAC-SOP-002 Failure Logging and Analysis.

Pass when. Each failure has an analysis and a preventive action.

Immediate fail (any one means the criterion is not met)

• A critical service has no named owner or back-up, and a failure is not analysed.

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Planned course: Planned fault prevention and maintenance. New course planned.

Why it matters. Endoscopes can carry infection from one patient to the next if they are not reprocessed correctly. Each use must follow a documented standard, with the equipment tested and recorded.

Sample. Select the endoscopes in use and trace their reprocessing for the last month.

1. Every endoscope is tested and maintained on schedule.

Method. Check each device’s test record against the schedule.

Evidence to show. EQP-REG-002 Reprocessing and Test Log (endoscopy).

Pass when. Each device has its test recorded on schedule.

2. Reprocessing follows a documented, validated procedure.

Method. Check the procedure and the validation record.

Evidence to show. EQP-SOP-002 Endoscope Reprocessing Standard.

Pass when. The procedure is approved and validated.

3. Each procedure can be traced to its device and cycle.

Method. Select three procedures and trace each one to its device and reprocessing cycle.

Evidence to show. EQP-REG-002 Reprocessing and Test Log (endoscopy).

Pass when. Each of the three procedures can be traced.

Immediate fail (any one means the criterion is not met)

• An endoscope is used with no recorded test or reprocessing cycle.

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Why it matters. A patient who is unsteady and walks along a corridor can fall where there is nothing to hold. Continuous handrails on both sides let them hold on for the whole route.

Sample. Walk 3 patient routes (ward corridor, stair or ramp, and route to the toilet) with the survey form on the day of assessment.

1. Handrails are fitted continuously on both sides of each corridor, stair and ramp.

Method. Walk each route and check both sides.

Evidence to show. Environmental falls-risk survey (ACS-FRM-001).

Pass when. Every route has continuous handrails on both sides.

2. The handrails are fixed and sturdy.

Method. Pull each handrail at three points on the walk.

Evidence to show. Survey record.

Pass when. No handrail moves under load.

3. Each quarterly survey is recorded.

Method. Check the survey dates for the last 12 months.

Evidence to show. Survey records.

Pass when. All four quarters are recorded, with findings closed.

Immediate fail (any one means the criterion is not met)

• A route used by patients has no handrail on one side, with no marking or action.

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Additional materials

Additional materials

Guidelines, definitions and articles on news.gmj.ge that relate to this criterion.

Definitions

• Fall in health care · GMJ dictionary

Why it matters. Toilet transfers are one of the most common moments of falls in care. Grab bars in the right place and fixed firmly give the patient something to hold.

Sample. Check 5 toilets and washrooms, including at least one accessible cubicle, on the day of assessment.

1. Grab bars are placed for toilet transfer.

Method. Check each toilet for horizontal and vertical bars.

Evidence to show. Toilet and washroom check (ACS-FRM-002).

Pass when. Every toilet checked has grab bars placed for transfer.

2. Grab bars are fixed and do not turn in their fittings.

Method. Apply force to each bar on the walk.

Evidence to show. Toilet and washroom check.

Pass when. No bar turns under load.

3. Defects are reported and fixed.

Method. Check the defect record for the last 12 months.

Evidence to show. Defect record.

Pass when. Every defect is fixed within the set time.

Immediate fail (any one means the criterion is not met)

• A grab bar turns in its fitting and is still used by patients.

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Additional materials

Why it matters. A patient who uses a wheelchair cannot use a toilet that is too small to turn in or has no bars to transfer with. At least one accessible toilet is needed for those patients to use the facility at all.

Sample. Check 5 toilets and washrooms, including at least one accessible cubicle, on the day of assessment.

1. At least one toilet is accessible for a wheelchair user.

Method. Measure the floor space and check the transfer bars.

Evidence to show. Accessibility check (ENV-FRM-001 and ACS-FRM-002).

Pass when. At least one accessible toilet is present, with the space and bars the guidance sets.

2. The accessible toilet is signed and reachable.

Method. Walk from the main route to the toilet.

Evidence to show. Walk record.

Pass when. The route is clear and signed.

3. The design meets recognised guidance.

Method. Compare the measurements with the guidance.

Evidence to show. Design check record.

Pass when. Measurements meet the guidance used.

Immediate fail (any one means the criterion is not met)

• No toilet in the facility can be used by a wheelchair user.

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Additional materials

Why it matters. A patient who falls behind a toilet door that opens inward may not be found in time. A door that opens outward, or that can be released from outside, lets staff reach the patient in an emergency.

Sample. Check 5 toilets and washrooms, including at least one accessible cubicle, on the day of assessment.

1. Toilet and washroom doors open outward, or release from outside.

Method. Open and release each door from outside on the walk.

Evidence to show. Toilet and washroom check (ACS-FRM-002).

Pass when. Every door opens outward or releases from outside.

2. The release works in an emergency.

Method. Test the release from outside with a staff member.

Evidence to show. Test record.

Pass when. Each release works when tested.

3. Staff know how to release a door.

Method. Ask 3 staff to show the release.

Evidence to show. Staff check record.

Pass when. At least 2 of 3 staff show it correctly.

Immediate fail (any one means the criterion is not met)

• A patient who has fallen behind a toilet door cannot be reached from outside.

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Why it matters. Patients get up at night and move in poor light. A dark corridor or toilet is where a fall is most likely. Adequate light, and night lighting, make the route safe at all hours.

Sample. Walk 3 patient routes (ward corridor, stair or ramp, and route to the toilet) with the survey form on the day of assessment.

1. Corridors, stairs, toilets, washrooms and rooms are lit at a safe level.

Method. Measure the light level at each point on the walk.

Evidence to show. Lighting check on the survey.

Pass when. Every area on the route meets the set level.

2. Night lighting or motion lighting is on the routes patients walk at night.

Method. Check the night route after dark.

Evidence to show. Night check record.

Pass when. Night lighting is working on every night route.

3. Lights that fail are reported and fixed.

Method. Check the fault record.

Evidence to show. Fault record.

Pass when. Every fault is fixed within the set time.

Immediate fail (any one means the criterion is not met)

• A patient route at night has no working light.

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Additional materials

Why it matters. A high bed is a common cause of falls when a patient climbs out. A low bed, with brakes on and the call bell in reach, keeps the patient safer in bed and on the way out.

Sample. Check 10 beds across the wards on the day of assessment, with the bed check records for the last 30 days.

1. Beds are set low when occupied, with brakes locked.

Method. Check each bed on the walk.

Evidence to show. Bed check (ACS-FRM-003).

Pass when. At least 90% of occupied beds are low with brakes locked.

2. The call system and personal items are within reach.

Method. Test the call system and check the reach from the bed.

Evidence to show. Bed check.

Pass when. Every bed checked has the call system in reach.

3. Beds are checked each shift.

Method. Check the records for the last 30 days.

Evidence to show. Bed check records.

Pass when. At least 90% of shifts have a recorded check.

Immediate fail (any one means the criterion is not met)

• A patient is in a high bed with the brakes off.

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Additional materials

Why it matters. A patient who needs a walking frame or a wheelchair but finds none, or finds one that is broken, is put at risk. Having the right aids, in the right sizes, and checking them on a schedule keeps them ready.

Sample. Check 10 walking aids and wheelchairs from the register, and the mobility equipment check records for the last 3 months.

1. Mobility equipment is available in the sizes needed.

Method. Compare the stock sizes with the needs of current patients.

Evidence to show. Mobility equipment register (ACS-REG-001).

Pass when. Every size needed is in stock.

2. Equipment is in working order.

Method. Check each item on the walk.

Evidence to show. Mobility equipment register.

Pass when. Every item in use works.

3. Equipment is checked on the defined schedule.

Method. Check the check dates against the schedule.

Evidence to show. Mobility equipment register.

Pass when. At least 90% of items are checked on time, and faulty items are out of use.

Immediate fail (any one means the criterion is not met)

• A faulty walking aid or wheelchair is in use with a patient.

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Additional materials

Definitions

Why it matters. A cable, a box or a mat on the floor is among the commonest causes of falls in a ward. Clear routes, with any hazard that cannot be removed marked, keep patients moving safely.

Sample. Walk 3 patient routes (ward corridor, stair or ramp, and route to the toilet) with the survey form on the day of assessment.

1. Patient routes are kept clear of trip hazards.

Method. Walk each route and record any hazard.

Evidence to show. Environmental falls-risk survey (ACS-FRM-001).

Pass when. No hazard is found on a route, or every hazard is marked.

2. Each hazard that cannot be removed is marked and managed.

Method. Check each marked hazard for the mark and the plan.

Evidence to show. Hazard record.

Pass when. Every marked hazard has a plan and an owner.

3. Staff are trained in falls prevention.

Method. Check the training record for the ward staff.

Evidence to show. Falls prevention training record (WRK-REG-005).

Pass when. At least 90% of ward staff are trained in the last 12 months.

Immediate fail (any one means the criterion is not met)

• A trip hazard is left on a patient route with no mark and no action.

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Additional materials

Why it matters. A facility uses energy, water and produces waste every day. A documented sustainability programme with targets turns that use into something that is measured and reduced.

Sample. Review the sustainability programme and its progress reports for the last 12 months.

1. A written programme exists and is approved.

Method. Read the programme and check the approval.

Evidence to show. Approved environmental sustainability programme.

Pass when. Approved, covers energy, waste and resource use, and names an owner.

2. Progress is tracked against targets.

Method. Review the progress report for the last 12 months.

Evidence to show. Sustainability progress report.

Pass when. At least two progress reports in the last 12 months with figures against targets.

3. Actions are recorded.

Method. Check the action list in the progress report.

Evidence to show. Action list.

Pass when. At least one action was taken from the last reporting cycle.

Immediate fail (any one means the criterion is not met)

• No environmental sustainability programme exists, or it has no written plan.

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Why it matters. Sustainability decisions made one purchase at a time never add up to a strategy. A strategic review, held by leadership, looks at the facility’s whole environmental impact and decides what to change.

Sample. Review the leadership environmental review for the last 12 months and the minutes where it was discussed.

1. Leadership reviews environmental impact.

Method. Read the review and check it covers energy, waste and resource use.

Evidence to show. Leadership environmental review record.

Pass when. Review done in the last 12 months, covering all three areas.

2. The review is discussed at leadership level.

Method. Check the minutes where the review was discussed.

Evidence to show. Leadership minutes.

Pass when. Discussed at a leadership meeting with a recorded decision.

3. Decisions are recorded.

Method. Check that decisions from the review have an owner.

Evidence to show. Decision log.

Pass when. At least one decision has an owner and a date.

Immediate fail (any one means the criterion is not met)

• Environmental impact is not reviewed at leadership level in the last 12 months.

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Why it matters. Staff and patients can help a sustainability goal only if they know what it is. Communicating the goals in plain words makes the approach something people do, not something on paper.

Sample. Review the sustainability communication plan and the notices issued in the last 12 months. Ask 3 staff and 3 patients what the goals are.

1. Goals are communicated to staff.

Method. Check the notices and the induction material.

Evidence to show. Sustainability notice and communication record.

Pass when. Goals were communicated to staff in the last 12 months.

2. Goals are communicated to patients.

Method. Check the patient-facing notices.

Evidence to show. Patient notice (template).

Pass when. A patient-facing notice is on display or in the patient information.

3. Staff and patients can describe the goal.

Method. Ask 3 staff and 3 patients what the facility is trying to do.

Evidence to show. Interview notes.

Pass when. At least 70% of those asked describe one goal correctly.

Immediate fail (any one means the criterion is not met)

• No communication about the sustainability goals reaches staff or patients.

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Why it matters. Goals that are never reported to the people who govern the facility are easily dropped. A set reporting schedule to governance keeps progress visible and acted on.

Sample. Review governance minutes and the progress reports for the last 12 months.

1. Progress is reported to governance on a set schedule.

Method. Check the governance minutes for the last 12 months.

Evidence to show. Governance minutes.

Pass when. Reported at least twice a year.

2. The report uses the agreed goals.

Method. Compare the report with the programme goals.

Evidence to show. Sustainability progress report.

Pass when. Each goal in the programme is reported on.

3. Governance responds to the report.

Method. Check the minutes for a decision or question after the report.

Evidence to show. Governance minutes.

Pass when. At least one recorded question or decision followed each report.

Immediate fail (any one means the criterion is not met)

• Sustainability progress is not reported to the governing body in the last 12 months.

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Why it matters. Purchases carry environmental and social costs: wasteful packaging, disposable products, and suppliers who exploit workers. Procurement that considers these reduces both.

Sample. Review the procurement policy and the supplier review records for the last 12 months. Check 5 recent purchase orders.

1. A responsible procurement policy exists.

Method. Read the policy and check its approval date.

Evidence to show. Responsible procurement policy.

Pass when. Approved and includes environmental and social criteria.

2. Suppliers are reviewed against the policy.

Method. Check the supplier review records.

Evidence to show. Supplier review record.

Pass when. At least 70% of the key suppliers were reviewed in the last 12 months.

3. Purchases reflect the policy.

Method. Check the 5 purchase orders for the criteria applied.

Evidence to show. Purchase order extract.

Pass when. At least 70% of the sampled orders show the criteria were applied or the reason is recorded.

Immediate fail (any one means the criterion is not met)

• Purchases are made with no supplier review or stewardship check.

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Why it matters. A facility that does not measure its energy use cannot reduce it. Monitoring electricity, gas and fuel, and taking steps away from the most polluting sources, is the first practical step.

Sample. Review the energy use records for the last 12 months and the reduction plan.

1. Energy use is recorded each month.

Method. Check the monthly energy use record for the last 12 months.

Evidence to show. Monthly energy use record.

Pass when. At least 10 of the last 12 months are recorded.

2. A reduction plan exists.

Method. Read the plan and check its last review date.

Evidence to show. Energy reduction and renewable options plan.

Pass when. Plan has at least one measure, an owner and a date, and was reviewed in the last 12 months.

3. Use is compared with the previous year.

Method. Compare the last 12 months with the previous year, or with the first recorded year.

Evidence to show. Energy use record.

Pass when. A comparison is recorded and the trend is reviewed by the owner.

Immediate fail (any one means the criterion is not met)

• Energy use is not monitored in the last 12 months.

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Why it matters. A carbon footprint shows where a facility’s greenhouse emissions come from. It does not need to be perfect; a basic baseline from energy and travel data is enough to start measuring change.

Sample. Review the carbon footprint baseline record and the method used.

1. A baseline assessment exists.

Method. Read the baseline record and check the date and the data used.

Evidence to show. Carbon footprint baseline record.

Pass when. Baseline is recorded with a date and a stated method.

2. The method is written down.

Method. Read the method and check it can be repeated.

Evidence to show. Baseline method (SOP).

Pass when. Method is approved and states its data sources and limits.

3. The baseline is used for monitoring.

Method. Check whether the baseline is compared with later data.

Evidence to show. Carbon footprint record.

Pass when. The baseline has been compared with at least one later period, or a plan to do so has an owner and a date.

Immediate fail (any one means the criterion is not met)

• No carbon footprint baseline exists.

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Why it matters. Floods, heatwaves, power cuts and disease outbreaks can stop a facility from working. Thinking ahead about how the service would keep running is part of keeping patients safe.

Sample. Review the climate and health emergency risk assessment, the continuity plan and the test records for the last 12 months.

1. Climate and health risks are assessed.

Method. Read the risk assessment and check it covers heat, flooding and other local hazards.

Evidence to show. Climate and health emergency risk assessment.

Pass when. Assessment covers at least two local hazards and is dated within the last 2 years.

2. A continuity plan exists.

Method. Read the plan and check it links to the assessment.

Evidence to show. Climate and health emergency continuity plan.

Pass when. Plan links each hazard to a continuity action and an owner.

3. The plan is tested.

Method. Check the continuity test record for the last 12 months.

Evidence to show. Continuity test record.

Pass when. At least one test in the last 12 months with a recorded result and actions.

Immediate fail (any one means the criterion is not met)

• No climate and health emergency plan exists, or no continuity test is recorded.

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Why it matters. A digital tool introduced into care without a check can slow care down, expose data, or fail when most needed. Assessing a tool before it is used, and managing it afterwards, protects the patient and the service.

Sample. Review the assessment for each digital care system in use.

1. A cost/benefit analysis is done before implementation.

Method. Check the assessment record dated before the go-live date.

Evidence to show. DIG-FRM-002 Digital Tool Assessment Template; DIG-SOP-002 Digital Care System Assessment and Management.

Pass when. The analysis is dated before go-live.

2. Interoperability is assessed.

Method. Check that the assessment covers integration with existing clinical systems.

Evidence to show. DIG-FRM-002 Digital Tool Assessment Template.

Pass when. Interoperability and its risks are recorded.

3. Unintended consequences are considered in advance.

Method. Check the record for an identified risk list and its mitigations.

Evidence to show. DIG-FRM-002 Digital Tool Assessment Template.

Pass when. The risk list is complete and each risk has a mitigation.

Immediate fail (any one means the criterion is not met)

• A digital care system is introduced with no cost/benefit analysis and no interoperability check.

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Why it matters. Some patients cannot use a phone app, do not have internet, or find video calls hard. A service that moves everything online without an alternative leaves those patients without care.

Sample. Select the digital care services in use and the records of patients who used the alternative route.

1. A defined alternative exists.

Method. Check the procedure for the alternative route.

Evidence to show. DIG-SOP-003 Digital Care Access and Alternatives.

Pass when. The alternative is defined and available.

2. The service was pre-tested with people who might struggle.

Method. Check the test record for a group of potential users.

Evidence to show. DIG-FRM-003 Digital Alternative Record.

Pass when. A pre-test with those users is recorded.

3. Patients using the alternative receive equivalent care.

Method. Select records of patients who used the alternative and compare the service they received.

Evidence to show. DIG-FRM-003 Digital Alternative Record.

Pass when. The service received is equivalent.

Immediate fail (any one means the criterion is not met)

• A patient who cannot use digital care has no alternative route, and receives reduced service.

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Why it matters. A digital system that no one can support when it fails leaves staff stuck and patients unseen. Access to technical expertise, in-house or from a vendor, keeps the system working when it matters.

Sample. Review the testing records and the support log for each digital care system.

1. Technical expertise is available.

Method. Check the support arrangement, in-house or contracted.

Evidence to show. DIG-PLN-001 Technical Support and Testing Arrangement.

Pass when. A named route to expertise exists.

2. Testing is done before full implementation.

Method. Check the test record dated before full use.

Evidence to show. DIG-FRM-004 Digital System Test and Support Record.

Pass when. Testing is recorded before full use.

3. Staff know the support route.

Method. Ask staff how they would get technical help for a digital system.

Evidence to show. DIG-PLN-001.

Pass when. Staff describe the route correctly.

Immediate fail (any one means the criterion is not met)

• A digital care system has no technical support route and was not tested before full use.

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Why it matters. Artificial intelligence can help with diagnosis and triage, but it can also make errors that look confident. WHO’s guidance on AI in health asks for safety, transparency and human oversight, and a facility that introduces AI must follow it.

Sample. Review the assessment and policy for each AI system in clinical use.

1. An assessment is made before introduction.

Method. Check the assessment against WHO guidance on the ethics and governance of AI for health.

Evidence to show. AI-FRM-001 AI System Assessment.

Pass when. Each system has an assessment that cites the guidance.

2. A responsible-use policy is in force.

Method. Check that the policy is approved and covers each system in use.

Evidence to show. AI-POL-001 Responsible Use of AI in Care Policy.

Pass when. The policy is approved and covers each system.

3. The facility can name its governance basis.

Method. Ask the responsible person for the governance basis of one named system.

Evidence to show. AI-FRM-001 AI System Assessment.

Pass when. The basis is named and recorded.

Immediate fail (any one means the criterion is not met)

• An AI system is in clinical use with no assessment and no governance basis.

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Why it matters. An AI system can work well at first and then drift, missing diagnoses or over-diagnosing as the patients change. Auditing its results regularly is the only way to notice.

Sample. Review the monitoring register for each AI system in use over the last 12 months.

1. AI output is audited for over- and under-diagnosis.

Method. Check the audit record for a sample of AI-assisted decisions.

Evidence to show. AI-SOP-001 AI Performance and Safety Monitoring.

Pass when. Audits are recorded for each system.

2. AI-related complaints are tracked.

Method. Check the complaints log for AI-related entries and their review.

Evidence to show. AI-REG-001 AI Monitoring Register.

Pass when. AI-related complaints are logged and reviewed.

3. A monitoring finding led to a response.

Method. Ask for one recorded case where monitoring found a problem and check the response.

Evidence to show. AI-REG-001 AI Monitoring Register.

Pass when. A recorded case shows a finding and a response.

Immediate fail (any one means the criterion is not met)

• An AI system’s output is not checked, and a known performance problem has no recorded response.

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Why it matters. Staff who will use an AI system every day know the practical problems that a manager may not. Consulting them before it is introduced finds those problems early.

Sample. Review the consultation record for each AI system introduced in the last 12 months.

1. Staff are consulted before introduction.

Method. Check the consultation record dated before the decision was final.

Evidence to show. AI-FRM-002 Staff Consultation Record.

Pass when. Consultation is recorded before the decision.

2. Training needs are identified and met before go-live.

Method. Check that the consultation identified training needs and that training was recorded before go-live.

Evidence to show. AI-SOP-002 Staff Consultation Before AI Introduction.

Pass when. Identified training was completed before go-live.

3. Staff can describe the consultation.

Method. Ask staff who use a recent AI system whether they were consulted.

Evidence to show. AI-FRM-002 Staff Consultation Record.

Pass when. Staff confirm the consultation took place.

Immediate fail (any one means the criterion is not met)

• An AI system goes live with no staff consultation before the decision was final.

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Why it matters. When an AI system contributes to a wrong decision, it is not clear who is responsible: the clinician, the vendor or the facility. A documented accountability arrangement answers that question before there is an incident.

Sample. Review the accountability policy and the records of AI-assisted decisions in the last 12 months.

1. Accountability is explicitly documented.

Method. Check the policy and a sample of AI-assisted decision records.

Evidence to show. AI-POL-002 Accountability for AI-Assisted Care.

Pass when. Clinical accountability is stated in the policy and the records.

2. Clinicians understand their accountability.

Method. Ask clinicians who use AI-supported tools to describe their accountability for the final decision.

Evidence to show. AI-POL-002 Accountability for AI-Assisted Care.

Pass when. Clinicians describe it correctly.

3. Accountability is reviewed after an incident.

Method. Check the process for any AI-related safety incident.

Evidence to show. AI-POL-002 Accountability for AI-Assisted Care; INC-SOP-001 Root Cause Analysis of Serious Incidents.

Pass when. A review of accountability follows any such incident.

Immediate fail (any one means the criterion is not met)

• Accountability for an AI-assisted decision is not documented, and no review follows an AI-related safety incident.

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Why it matters. A patient who is treated with the help of AI has a right to know. Telling them, rather than leaving them to assume, is part of informed consent and trust.

Sample. Review the patient information and the records of AI-supported care for the last 12 months.

1. Patients are informed when AI supports their care.

Method. Check the information given and the record of disclosure.

Evidence to show. AI-SOP-003 Informing Patients About AI-Supported Care.

Pass when. Disclosure is recorded for AI-supported care.

2. The information is understandable.

Method. Read the patient information for plain language and check it is not buried in a general consent form.

Evidence to show. AI-FRM-003 Patient Information on AI-Supported Care (template).

Pass when. The information is written in plain language and given separately.

3. Patients confirm they were told.

Method. Ask a sample of patients whether they were told AI was involved.

Evidence to show. AI-FRM-003 Patient Information on AI-Supported Care (template).

Pass when. Patients confirm they were informed.

Immediate fail (any one means the criterion is not met)

• A patient is not informed that AI supported their care, and no information is available.

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E-learning: who must take each course

Why it matters. Skills learned at hiring fade. Checking competence against the actual job, on a schedule, finds gaps before they harm patients.

Sample. Select three roles and review the competency records for their current staff.

1. Competency is evaluated on a defined schedule.

Method. Compare the evaluation dates with the schedule in the procedure.

Evidence to show. WRK-SOP-001 Annual competency assessment procedure; WRK-REG-001 Training matrix register.

Pass when. Evaluations are recorded on the scheduled dates.

2. The evaluation covers the person’s current role.

Method. Check that the competency form matches the role description.

Evidence to show. WRK-FRM-001 Competency assessment form by role.

Pass when. The form covers the current role.

3. Gaps have a defined response.

Method. Check each recorded gap for an action and a date.

Evidence to show. WRK-POL-001 Ongoing competency evaluation policy.

Pass when. Each gap has an action and a date.

Immediate fail (any one means the criterion is not met)

• A staff member with a current competency gap is kept in role with no evaluation and no response.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Staff who cannot learn new skills fall behind the care they are asked to give. Giving every staff member access to ongoing education keeps the workforce able to meet the standards.

Sample. Review the training matrix for the last 12 months.

1. Every workforce member has ongoing education access.

Method. Check the training matrix for each person.

Evidence to show. WRK-REG-001 Training matrix register.

Pass when. Each person has at least one recorded entry beyond induction.

2. Development goes beyond the minimum.

Method. Check the entries for development opportunities beyond the required minimum.

Evidence to show. WRK-POL-002 Learning, training and competence policy.

Pass when. Development entries exist beyond the minimum.

3. Staff can describe a recent opportunity.

Method. Ask staff to name an education opportunity taken in the last year.

Evidence to show. WRK-REG-001 Training matrix register.

Pass when. Staff name a recorded opportunity.

Immediate fail (any one means the criterion is not met)

• A staff member has had no education beyond induction and no development route exists.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Health workers can catch infections and be hurt at work, and they can also carry infections to patients. Protecting their health, with required vaccinations and safe working conditions, protects everyone in the building.

Sample. Review the vaccination records and the exposure records for the last 12 months.

1. Protective equipment is available and used.

Method. Check stock and observe use in two clinical areas.

Evidence to show. WRK-POL-003 Occupational health, safety and wellbeing policy.

Pass when. Equipment is in stock and used.

2. Needlestick and manual handling measures are in place.

Method. Check the exposure procedure and the manual handling measures.

Evidence to show. WRK-SOP-002 Occupational exposure and needlestick response.

Pass when. Concrete measures exist and are followed.

3. Vaccinations are tracked and current.

Method. Check the vaccination record for each staff member against the required schedule.

Evidence to show. WRK-SOP-003 Staff vaccination and immunisation.

Pass when. Required vaccinations are recorded as current.

Immediate fail (any one means the criterion is not met)

• Required staff vaccinations are not tracked, or needlestick and manual handling risks have no protective measures.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. When staff raise a problem at work, such as unsafe rotas or bullying, and nothing happens, they stop raising it. A process that investigates and resolves the issue keeps problems visible and fixed.

Sample. Review the concern records for the last 12 months.

1. An accessible process exists to raise issues.

Method. Check the procedure and ask staff how they would raise a whistleblowing concern.

Evidence to show. WRK-SOP-005 Staff grievance and investigation procedure.

Pass when. The process is written and staff can describe it.

2. Raised issues are investigated and resolved.

Method. Check each recorded concern for an investigation and an outcome.

Evidence to show. WRK-FRM-002 Staff concern and investigation record.

Pass when. Each concern has an investigation and an outcome.

3. Staff are protected from adverse treatment.

Method. Check the records for any adverse action following a concern.

Evidence to show. WRK-SOP-005 Staff grievance and investigation procedure.

Pass when. No adverse action follows a raised concern without review.

Immediate fail (any one means the criterion is not met)

• A raised concern has no investigation record, or a staff member who raised one is treated adversely.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Staff who are attacked need specific protections, not general statements. Tracking incidents shows whether the protections work.

Sample. Review the incident records for the last 12 months.

1. Specific protective measures exist.

Method. Check the prevention procedure for concrete measures.

Evidence to show. WRK-SOP-006 Violence and aggression prevention and response.

Pass when. Concrete measures are written in the procedure.

2. Incidents are recorded and reviewed.

Method. Check each recorded incident for a review.

Evidence to show. WRK-FRM-003 Violence and aggression incident record.

Pass when. Each incident is recorded and reviewed.

3. A measure has worked in practice.

Method. Ask staff to describe a case where a measure worked as intended.

Evidence to show. WRK-FRM-003 Violence and aggression incident record.

Pass when. Staff describe at least one case.

Immediate fail (any one means the criterion is not met)

• A violent or aggressive incident against staff is not recorded.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Staff know where the service is failing better than anyone. Asking them regularly, and acting on the answers, is how the workforce’s experience improves the service.

Sample. Review the feedback surveys and responses for the last 12 months.

1. Feedback is gathered on a recurring basis.

Method. Check the survey schedule and the records of exit interviews and consultations.

Evidence to show. WRK-FRM-004 Staff feedback survey template; WRK-SOP-007 Staff feedback survey and response.

Pass when. Feedback is gathered on a schedule.

2. Feedback is analysed for trends.

Method. Check the analysis of the latest survey.

Evidence to show. WRK-SOP-007 Staff feedback survey and response.

Pass when. An analysis of trends is recorded.

3. Feedback has led to a change.

Method. Ask for one implemented change that came from feedback.

Evidence to show. WRK-SOP-007 Staff feedback survey and response.

Pass when. At least one change is recorded.

Immediate fail (any one means the criterion is not met)

• No workforce feedback is gathered, or feedback is collected and never analysed.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step

E-learning: who must take each course

Why it matters. Sick leave and staff leaving are early warnings. When many people are off sick or leaving one ward, the cause is often in the workload or the management, and it can be found in the data.

Sample. Review the sickness and attrition register for the last 12 months.

1. Sick leave data is monitored.

Method. Check the register for a recorded review of sick leave.

Evidence to show. WRK-REG-002 Sickness absence and turnover register.

Pass when. Reviews are recorded.

2. Reasons for leaving are captured.

Method. Check the exit records for a recorded reason for each leaver.

Evidence to show. WRK-SOP-008 Analysis of sickness and attrition data.

Pass when. A reason is recorded for each leaver.

3. The data has informed a change.

Method. Ask for one recorded change that followed the analysis.

Evidence to show. WRK-SOP-008 Analysis of sickness and attrition data.

Pass when. At least one change is recorded.

Immediate fail (any one means the criterion is not met)

• Sick leave and attrition data are recorded but never reviewed.

Staff, training and documents

Read across each row to see who does each step. Click a document name for its full text.

Staff responsible

Which level applies to you: it depends on your setting. Humanitarian settings have the fewest essential courses; standard settings have the most. Check the colour for your setting in each criterion.

Documents: who does each step