Standards › ASF Health Standards v10 › Standard 2A · Single-Service Providers (minimum set)

Standard 2A · Single-Service Providers (minimum set)

7 criteria · ASF Health Standards v10 · Draft for review

Each criterion below shows what the surveyor checks, the evidence to show, and what counts as met, partly met or not met.

Colour key: Red = Essential, required in every setting. Green = Recommended. Amber = Standard.

2A.M1 A Named Person Is Accountable for the Service

Non-negotiable

One named person holds documented accountability for the safety and quality of the service, and can be identified by staff and patients. Where the provider has an owner or board, that body is named instead, with the same accountability.

Questions the surveyor asks

1. Is one named person accountable for the service, and is their name known to staff and patients? Accountability shared by no one is not accountability.
2. Is the accountable person's authority to stop unsafe care written down? Authority to act is only useful when it is recorded.

Why it matters. A single-service provider with no one clearly accountable has no one to answer for a failure. Naming one person, who staff and patients can identify, makes accountability real even in a very small service.

Evidence to show. Written accountability statement naming the person, and the staff notice showing who it is.

Good

• one named person with written accountability for safety and quality, known to staff and displayed to patients.

Failure

• no one identified as accountable for the service.

Partly met when

• Not known to staff: A named person that staff cannot identify.
• Accountability not written: The person is named but the accountability is not documented.

How to implement

• Once: Name the accountable person and write the accountability.
• Each year: Confirm the person and tell staff.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask a staff member: who is responsible for safety here, and what would you do if you had a concern?
• What is uploaded: Written accountability statement naming the person, and the staff notice showing who it is.

E-learning. Governance and Management

2A.M2 The Service Has a Written Operating Plan and Policies

Non-negotiable

The service has a short written plan that says what it provides, for whom, and how it keeps people safe, together with the policies that follow from it. The plan is reviewed at least once a year.

Questions the surveyor asks

1. Is there a written plan describing the services, the patients and the safety arrangements? Without a written plan, no one can check what the service is meant to do.
2. Is the plan reviewed at least once a year, with the review recorded? A plan that is not reviewed stops matching practice.

Why it matters. A small service that works without a written plan depends on memory, and changes in staff lose what the service does and why. A short written plan with its policies keeps the service consistent.

Evidence to show. Written operating plan (current, dated) with the list of its policies.

Good

• a short plan stating what the service provides, for whom and how it keeps people safe, with its policies attached.

Failure

• no written plan, and services described differently by each staff member.

Partly met when

• Policies not attached: A plan with no policies behind it.
• Plan out of date: The plan does not match the service actually provided.

How to implement

• Once: Write the short operating plan.
• Each year: Review the plan against what the service provides.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask a staff member: what does this service provide, and who is it for?
• What is uploaded: Written operating plan (current, dated) with the list of its policies.

E-learning. Quality Management in Healthcare

2A.M3 Policies Are Followed in Practice

Non-negotiable

Written policies are followed in daily practice, and departures are noticed and corrected.

Questions the surveyor asks

1. Can staff describe the key policies, and do they follow them when observed? A policy that exists only on paper protects no one.
2. Are departures from policy recorded and acted on? Departures that are not recorded cannot be corrected.

Why it matters. A written policy that is not followed does not protect anyone. In a small service, the gap between the policy and daily practice is often the place where the error happens.

Evidence to show. Record of policy checks for the last 3 months and the corrections made.

Good

• staff apply the policies in daily work, and departures are noticed and corrected.

Failure

• a policy on hand-washing never applied in practice.

Partly met when

• Departures ignored: Departures noticed but not corrected.
• Not applied: Policy written but staff do not follow it in practice.

How to implement

• Each month: Check how a sample of policies is applied.
• When found: Correct the departure and record it.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask a staff member: show me how you apply the policy on handling a complaint in your work today.
• What is uploaded: Record of policy checks for the last 3 months and the corrections made.

E-learning. Quality Management in Healthcare

2A.M4 Patient Data Is Kept Secure

Non-negotiable

Patient information is stored securely, is accessed only by people who need it, and is protected from loss.

Questions the surveyor asks

1. Is patient information stored securely, with access limited to people who need it? Unrestricted access makes confidentiality a matter of chance.
2. Is there a back-up of patient records, tested at least once a year? A back-up that has never been restored may not work.

Why it matters. Patient information is private, and it can be lost or stolen in a moment. Storage, access and protection rules that are written and followed keep it safe.

Evidence to show. Access rules (current) and the access review record (last 3 months).

Good

• patient data stored securely; access limited to people who need it; loss prevented by backup and locking.

Failure

• records left open on a desk or shared by email.

Partly met when

• Access not reviewed: Access is granted but not reviewed.
• Records left open: Records are left where others can see them.

How to implement

• Week 1: Write the access rules for patient records.
• Week 2: Review who has access and remove the unneeded.
• Monthly: Audit access logs.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask a staff member: who can see patient records here, and how would you know if someone looked at a record they should not?
• What is uploaded: Access rules (current) and the access review record (last 3 months).

E-learning. Information security, LIS downtime, backup and data protection

2A.M5 Records Are Kept for the Required Period

Non-negotiable

Records are kept for at least the period set in the facility's written retention schedule, and can be retrieved when needed.

Questions the surveyor asks

1. Is there a written retention period that meets the minimum stated in the facility's retention schedule? Retention set by habit is not a standard.
2. Can a record from several years back be retrieved within that period? A record that cannot be found is no record.

Why it matters. Records are needed for care, for legal questions and for the next patient. A written retention schedule, followed, makes sure they exist when they are needed.

Evidence to show. Retention schedule (current) and the retrieval test record.

Good

• a written retention schedule; records kept for the set period; retrieval tested.

Failure

• records destroyed early or lost.

Partly met when

• Schedule not followed: The schedule is written but not followed.
• Electronic not covered: The schedule applies to paper only.

How to implement

• Week 1: Write the retention schedule for paper and electronic records.
• Week 2: Test retrieval of an old record.
• Yearly: Review the schedule and the disposals.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask the records officer: how long do you keep a call record, and how would you find one from two years ago?
• What is uploaded: Retention schedule (current) and the retrieval test record.

E-learning. Documentation Fundamentals

2A.M6 Serious Incidents Are Investigated

Non-negotiable

Every serious incident is investigated, with the findings and any change in practice recorded.

Questions the surveyor asks

1. Is every serious incident investigated, with the investigation recorded? An incident that is not investigated repeats.
2. Is each investigation followed by a recorded change in practice where one is needed? Learning that changes nothing protects no one.

Why it matters. A serious incident is a signal that the system failed. Investigating every one, and recording what changed, is how the same incident is prevented from happening again.

Evidence to show. Serious incident log (last 12 months) with investigations and changes made.

Good

• every serious incident investigated; findings and any change in practice recorded.

Failure

• serious incident closed with no investigation.

Partly met when

• Change not recorded: The investigation happens but the change is not recorded.
• Blame only: The investigation names a person and ends there.

How to implement

• Week 1: Set the serious incident definition and the investigation route.
• Week 2: Record each investigation and change.
• Monthly: Review open investigations.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask the quality lead: what was the last serious incident, and what changed as a result?
• What is uploaded: Serious incident log (last 12 months) with investigations and changes made.

E-learning. Quality Management in Healthcare

2A.M7 Patients Are Asked for Feedback at Least Once a Year

Standard

The service asks its patients and families for feedback at least once a year, and records what it changed as a result.

Questions the surveyor asks

1. Is feedback from patients and families collected at least once a year? A service that does not ask cannot learn what is wrong.
2. Is at least one recorded change made as a result of feedback? Feedback with no response stops coming.

Why it matters. A small service can seem to run well while patients quietly stop coming back. Asking patients once a year, and changing something as a result, is a simple way to find out what they think.

Evidence to show. Feedback form, the summary of the last year's responses, and the change recorded from them.

Good

• patients and families asked for feedback each year, with the change made from it recorded.

Failure

• no feedback asked in the last three years.

Partly met when

• Nothing changed: Feedback asked but no change recorded.
• Not asked: No feedback asked in the year.

How to implement

• Each year: Ask patients and families for feedback.
• Each year: Record the change made as a result.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask a patient: when were you last asked for your views on this service, and did anything change?
• What is uploaded: Feedback form, the summary of the last year's responses, and the change recorded from them.

E-learning. Complaints Handling and Patient Feedback