Standards › ASF Health Standards v10 › Standard 44
Standard 44
Access, Findability and Wayfinding
Access, findability and wayfinding: public information, marked emergency entrance, accessible signs, tested routes, and access information kept current..
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
44.1Patients Can Find the Service Before They ArriveHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Public information states the address, opening hours, how to reach the service by public transport and by road, the languages spoken, and the emergency arrangements. It is checked at a defined interval.
Why it matters. A patient who cannot find the clinic before arriving may give up or arrive at the wrong place. Clear public information about the address, hours and how to get there helps the patient reach care.
How the surveyor verifies this criterion
Sample. Review public information on the website, listings and printed materials for the last 3 months.
1. Public information states the address, opening hours and how to get there.
Method. Compare each public source with the current address and hours.
Evidence to show. Public information about the service (WAY-POL-001).
Pass when. Every public source matches the current address and hours.
2. The languages spoken and the emergency contact are stated.
Method. Check each public source for the languages and the emergency number.
Evidence to show. Public information check record (WAY-FRM-001).
Pass when. Every public source states the languages and emergency contact.
Immediate fail (any one means the criterion is not met). A family travels to a clinic that has moved, with public information never updated.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the Public information about the service | Medium |
| Nurse (ISCO 2221) | Completes the Public information check record | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| WAY-FRM-001 · Public information check record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| WAY-POL-001 · Public information about the service | Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Access & Arrival: Getting Patients Through the Door (H-01) | Manager; Nurse |
References
In process of development. Will be available soon.
44.2The Emergency Entrance Is Clearly Marked and OpenHumanitarian settings: MinimumTransition and fragile: MustStandard: Must
The emergency entrance is marked from the road and inside the site, and is open whenever emergency patients may arrive. Ambulance access is kept clear.
Why it matters. In an emergency the patient must find the entrance at once. A marked, lit and open emergency entrance is part of the emergency plan.
How the surveyor verifies this criterion
Sample. Inspect the emergency entrance and its approach on three days, including one night.
1. The emergency entrance is marked from the road and inside the site.
Method. Inspect the road and internal signs to the entrance.
Evidence to show. Emergency entrance marking and access (WAY-SOP-001).
Pass when. The entrance is marked from the road and inside.
2. The entrance is open whenever emergency patients may arrive.
Method. Check the open-hours record against the times emergency patients arrive.
Evidence to show. Emergency entrance open-hours and clear-access check register (WAY-REG-001).
Pass when. The entrance was open at every sampled time.
Immediate fail (any one means the criterion is not met). The emergency entrance locked and signed to the car park, and an ambulance waits 15 minutes.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the Emergency entrance marking and access | Must |
| Secretary (ISCO 3344) | Keeps the Emergency entrance open-hours and clear-access check | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| WAY-SOP-001 · Emergency entrance marking and access | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| WAY-REG-001 · Emergency entrance open-hours and clear-access check register | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Access & Arrival: Getting Patients Through the Door (H-01) | Manager; Nurse |
References
- Building construction – Accessibility and usability of the built environment (ISO 21542:2021) (International Organization for Standardization, 2021)
44.3Signs Work for People With Limited Literacy or SightHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Signs use symbols and pictograms alongside text, have good contrast, and are in the languages the population uses. Tactile or audio support is available where the population needs it.
Why it matters. Not everyone can read well or see small text. Signs with pictures alongside words, good contrast and large print help everyone find their way.
How the surveyor verifies this criterion
Sample. Inspect the main signage on the site and check it against the languages and literacy needs of the population.
1. Signs have good contrast and are in the languages the population uses.
Method. Check each sign for contrast and language.
Evidence to show. Accessible signage check record (WAY-FRM-002).
Pass when. Every sign has good contrast and the required languages.
Immediate fail (any one means the criterion is not met). A deaf patient and a patient with low sight cannot find the lab; signs are text only.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Nurse (ISCO 2221) | Completes the Accessible signage check record | Medium |
| Manager (ISCO 1342) | Checks the criterion at each review | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| WAY-FRM-002 · Accessible signage check record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Reception & Information: The First Ten Minutes (H-02) | Manager; Nurse |
References
- WHO (2024). Implementation toolkit for accessible telehealth services. Used for: Accessible telehealth toolkit: accessible information for people with disability and limited literacy. Telehealth-specific, not physical signage. https://news.gmj.ge/guideline/implementation-toolkit-for-accessible-telehealth-services/
44.4The Route to Key Services Is Marked and TestedHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
The routes to key services are marked on the site and tested with real users at a defined interval. Changes to the building trigger a new test.
Why it matters. A patient who gets lost on the way to a service may miss their appointment or arrive late. Routes marked and tested with real people show where the problems are.
How the surveyor verifies this criterion
Sample. Review route tests for all key services in the last 12 months, and any building change in that period.
1. The routes to key services are marked on the site.
Method. Walk each route and check the marking.
Evidence to show. Route marking and user testing (WAY-SOP-003).
Pass when. Every key route is marked.
2. Routes are tested with real users at the defined interval.
Method. Check the route test register for each route against the interval.
Evidence to show. Route test register (WAY-REG-002).
Pass when. Every key route was tested with users at the interval.
3. A building change triggers a new route test.
Method. Check each building change for a route test within the defined time.
Evidence to show. Route test register (WAY-REG-002).
Pass when. Every building change has a route test recorded.
Immediate fail (any one means the criterion is not met). Route to the dialysis unit never tested with patients; patients walk into the wrong wing.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the Route marking and user testing | Medium |
| Secretary (ISCO 3344) | Keeps the Route test register | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| WAY-SOP-003 · Route marking and user testing | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| WAY-REG-002 · Route test register | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Access & Arrival: Getting Patients Through the Door (H-01) | Manager; Nurse |
References
In process of development. Will be available soon.
44.5Access Information Is Kept Current Through ChangeHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
The service records who is responsible for access information. Changes to the site, the entrance, the hours or the services offered trigger an update before the change takes effect.
Why it matters. Access information changes when a building is altered, a door is moved or a route is closed. Someone must be responsible for keeping it current, or the information becomes wrong.
How the surveyor verifies this criterion
Sample. Review the access information change log and the current public information for the last 12 months.
1. The service records who is responsible for access information.
Method. Check the policy for the named responsible person.
Evidence to show. Keeping access information current (WAY-POL-002).
Pass when. A responsible person is named and recorded.
2. Each change to the site, entrance, hours or services triggers an update.
Method. Check each recorded change against the update made to public information.
Evidence to show. Access information change log (WAY-REG-003).
Pass when. Every change has an update recorded within the defined time.
3. Public information matches the current site after each change.
Method. Compare the public information with the site after a sample of changes.
Evidence to show. Access information change log (WAY-REG-003).
Pass when. Public information matches the site after every sampled change.
Immediate fail (any one means the criterion is not met). The emergency entrance moved in June and the website still shows the old address.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the Keeping access information current | Medium |
| Secretary (ISCO 3344) | Keeps the Access information change log | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| WAY-REG-003 · Access information change log | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| WAY-POL-002 · Keeping access information current | Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Access & Arrival: Getting Patients Through the Door (H-01) | Manager; Nurse |
References
In process of development. Will be available soon.
Who is responsible for Standard 44
Each criterion names the positions responsible for it. Every position links to its own terms of reference.
| Criterion | Responsible | Supports |
|---|---|---|
| 44.1 Patients Can Find the Service Before They Arrive | Patient services manager Receptionist |
Facilities manager |
| 44.2 The Emergency Entrance Is Clearly Marked and Open | Facilities manager Head of emergency department |
Risk manager |
| 44.3 Signs Work for People With Limited Literacy or Sight | Facilities manager Patient advocate |
Interpreter (medical) |
| 44.4 The Route to Key Services Is Marked and Tested | Facilities manager General maintenance technician (handyman) |
Risk manager |
| 44.5 Access Information Is Kept Current Through Change | Patient services manager Facilities manager |
Complaints and patient experience officer |
Role details: reporting, supervision and training
Training shown is the general recommendation. Role-specific training is set in the next improvement round.
| Role | Reports to | Supervises | Recommended training |
|---|---|---|---|
| Risk manager | Chief quality and safety officer | None | Facility induction; safeguarding adults (general recommendation) |
| Complaints and patient experience officer | Quality manager | None | Facility induction; safeguarding adults (general recommendation) |
| Interpreter (medical) | Patient services manager | None | Facility induction; safeguarding adults (general recommendation) |
| Patient advocate | Complaints and patient experience officer | None | Facility induction; safeguarding adults (general recommendation) |
| Head of emergency department | Medical director | Triage nurse, Emergency nurse | Facility induction; safeguarding adults (general recommendation) |
| Patient services manager | Chief operating officer (COO) | Admissions officer, Receptionist, Appointments clerk, Medical records manager, Bed manager / patient flow coordinator | Facility induction; safeguarding adults (general recommendation) |
| Receptionist | Patient services manager | None | Facility induction; safeguarding adults (general recommendation) |
| Facilities manager | Chief operating officer (COO) | Biomedical engineer, Maintenance supervisor, Gardener / groundskeeper, Architect / space planner, Waste management officer | Facility induction; safeguarding adults (general recommendation) |
| General maintenance technician (handyman) | Maintenance supervisor | None | Facility induction; safeguarding adults (general recommendation) |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 36 apply to?
Health services that patients and the public must find, enter and move around, including hospitals, clinics and any site with an emergency entrance.
What do the colours mean for this standard?
Red (Must) is required. Green (Medium) is recommended. Yellow (Minimum) is the lowest acceptable level in humanitarian settings. Standard setting is Must on every criterion.
What must patients know before they arrive?
Under 44.1 public information gives the address, opening hours, how to get there, the languages spoken and the emergency arrangements, checked at a defined interval.
Is the emergency entrance always open?
Under 44.2 the emergency entrance is marked from the road and inside the site, is open whenever emergency patients may arrive, and ambulance access is kept clear.
Do signs work for people who cannot read well?
Under 44.3 signs use symbols and pictograms with text, have good contrast, and are in the languages the population uses.
Are routes to key services tested?
Under 44.4 routes to key services are marked and tested with real users at a defined interval, and a building change triggers a new test.
How is access information kept accurate?
Under 44.5 a named person is responsible for access information, and changes are updated before they take effect.
Guidelines for this standard
3 guideline(s) are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.
- Health Building Note 15-01: Accident & emergency departments – Planning and design guidance (Dept of Health)
- Building construction – Accessibility and usability of the built environment (ISO 21542:2021) (ISO)
- Global action plan on the public health response to dementia 2017–2025 (2017) (World Health Organization)