ASF Health Standards Version 11

• 1.1Staffing Matches Patient Need
• 1.2Every Patient Gets a Structured Assessment
• 1.3There is an Actual Care Plan
• 1.4Restraint and Seclusion Use Is Governed and Minimised
• 1.5Nutrition and Therapeutic Diet Needs Are Actively Managed
• 1.6Pressure Injury Risk Is Assessed and Actively Prevented
• 1.7VTE Risk Is Assessed Before Every Admission and Procedure

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• 2-1.1The Board Is Accountable
• 2-1.2There Is a Written Strategic Plan
• 2-1.3Policy Gets Followed
• 2-1.4Patient Data Is Kept Secure
• 2-1.5Records Are Kept Exactly as Long as Required
• 2-1.6Serious Incidents Get Properly Investigated
• 2-1.7Safety Culture Is Measured
• 2-1.8Patient Experience Is Measured Continuously, Not Only After Discharge
• 2-1.9An Ethics Consultation Process Exists
• 2-1.10Patients and Families Have a Voice in Governance

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• 2-2.1Reception Desk Accessibility
• 2-2.2Waiting and Queue Time Is Actively Managed
• 2-2.3Water Supply Is Safe and Monitored
• 2-2.4Medical Equipment Is Maintained on Schedule
• 2-2.5Shared Spaces Are Clean
• 2-2.6Facility Risks Are Tracked in One Integrated Register
• 2-2.7Facility Signage Is Complete Throughout the Building
• 2-2.8Fault Prevention Is Planned, Not Only Repaired
• 2-2.9Endoscopy Equipment Is Safe to Use and Properly Reprocessed
• 2-2.10Handrails Are Fitted Where Patients Walk
• 2-2.11Toilets and Washrooms Have Correct Grab Bars
• 2-2.12An Accessible Toilet Is Available Where Patients Need One
• 2-2.13Toilet and Washroom Doors Allow Rescue
• 2-2.14Lighting Supports Safe Movement
• 2-2.15Beds and Chairs Are Set to Reduce Fall Risk
• 2-2.16Walking Aids and Mobility Equipment Are Available and Checked
• 2-2.17Routes Are Clear of Clutter and Trip Hazards

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• 2-3.1An Environmental Sustainability Programme Is Active
• 2-3.2Environmental Impact Is Reviewed at Strategic Level
• 2-3.3Staff and Patients Are Informed of Sustainability Goals
• 2-3.4Sustainability Progress Is Reported to Governance
• 2-3.5Procurement Considers Responsible Stewardship of Resources
• 2-3.6Energy Use Is Monitored, With a Move Toward Renewable Sources
• 2-3.7A Carbon Footprint Baseline Exists
• 2-3.8The Facility Plans for Environmental and Climate Resilience

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• 2-4.1Digital Care Systems Follow an Assessment and Management Process
• 2-4.2Digital Care Never Disadvantages a Patient Who Cannot Use It
• 2-4.3Technical Expertise Supports Digital Care Systems
• 2-4.4AI Systems Are Introduced in Line With WHO AI Governance Guidance
• 2-4.5AI Systems Are Monitored for Unintended Consequences
• 2-4.6Staff Are Consulted Before an AI System Is Introduced
• 2-4.7Accountability for AI-Assisted Care Is Explicitly Defined
• 2-4.8Patients Are Informed When Their Care Involves AI

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• 2-5.1Ongoing Competency Is Regularly Evaluated
• 2-5.2Staff Have Access to Ongoing Education and Skill Development
• 2-5.3Workforce Health and Safety Is Protected
• 2-5.4Workplace Issues Raised by
• 2-5.5Staff Are Protected From Violence and Aggression
• 2-5.6Workforce Feedback Is Gathered and Acted On
• 2-5.7Sick Leave and Attrition Data Inform Organisational Learning
• 2-5.8Equality, Diversity and Inclusion Across the Workforce Are Monitored
• 2-5.9Working Hours and Rest Are Safe
• 2-5.10Staff Can Raise Concerns Through a Route That Protects Them
• 2-5.11Staff Are Trained in Falls Prevention

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• 7.1The Surgical Safety Checklist Is Used
• 7.2Anaesthesia Is Delivered Safely
• 7.3Surgical Site Infection Is Actively Prevented
• 7.4Procedures Are Performed Within Granted Privileges and Marked Correctly
• 7.5Post-Operative Monitoring and Recovery Are Safe
• 7.6Instrument, Swab and Sharps Counts Are Completed

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• 8.1Look-Alike, Sound-Alike Medications Are Specifically Managed
• 8.2Each Prescription Is Checked Before Dispensing
• 8.3High-Alert Medicines Are Double-Checked Before Giving
• 8.4Medicines Are Stored Securely and at the Right Temperature
• 8.5Controlled Medicines Are Recorded and Counted
• 8.6Medicines Are Reconciled at Admission, Transfer and Discharge
• 8.7Medication Errors Are Reported and Reviewed

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• 9.1Handrails Are Fitted Where Patients Walk
• 9.2Toilets and Washrooms Have Correct Grab Bars
• 9.3An Accessible Toilet Is Available Where Patients Need One
• 9.4Toilet and Washroom Doors Allow Rescue
• 9.5Lighting Supports Safe Movement
• 9.6Beds and Chairs Are Set to Reduce Fall Risk
• 9.7Walking Aids and Mobility Equipment Are Available and Checked
• 9.8Routes Are Clear of Clutter and Trip Hazards

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• 10.1Opioid Prescribing Is Deliberately Stewarded
• 10.2Pain Is Formally Assessed and Reassessed, Not Just Asked About Once
• 10.3Pain and Symptoms Are Assessed and Controlled
• 10.4Opioids and Controlled Medicines Are Managed Safely
• 10.5Patients and Families Are Informed About Their Pain Plan

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• 34.1Individualised Rehabilitation Plan Based on Functional Assessment
• 34.2Multidisciplinary Team Coordination
• 34.3Patient and Family Goal-Setting and Education
• 34.4Progress Is Measured With Validated Functional Outcome Tools
• 34.5Equipment and Assistive Device Provision Matches Need
• 34.6Discharge and Community Reintegration Planning
• 34.7Each Patient Has a Clinical Assessment Before Treatment
• 34.8Every Discharged Patient Has an Aftercare Plan
• 34.9Patients Are Given Advice to Continue at Home

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• 35.1Continuous Physiological Monitoring Appropriate to Acuity
• 35.2Nurse-to-Patient Ratio Matches Acuity
• 35.3Rapid Response and Deterioration Recognition System
• 35.4Sedation and Delirium Management Protocol
• 35.5Family Communication and Presence Policy
• 35.6End-of-Life and Withdrawal of Care Protocol
• 35.7Deteriorating Patients Are Recognised Early
• 35.8Dying Patients Are Cared for With Dignity

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• 43.1Donor Consent Obtained Through a Process Independent of the Transplant Team
• 43.2Organ Allocation Follows a Transparent, Documented Protocol
• 43.3No Financial Incentive to Donor or Family
• 43.4Recipient Evaluation and Informed Consent Process
• 43.5Organ and Tissue Traceability, End to End
• 43.6Post-Transplant Follow-Up and Outcome Tracking

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• 50.1Radiation Dose Optimisation and Justification
• 50.2Equipment Quality Assurance and Calibration
• 50.3Timely, Accurate Reporting With Critical Finding Escalation
• 50.4Contrast Media Safety Protocol
• 50.5MRI Safety Screening and Zone Control
• 50.6Image and Report Retention, Accessible for Comparison
• 50.7Resuscitation Equipment Is Ready Right Now

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• 51.1Cytotoxic Drug Handling Follows a Verified Safe-Handling
• 51.2Chemotherapy Dose Is Verified by Independent Two-Person Check
• 51.3Neutropenic Fever Triggers an Immediate, Time-Bound Response
• 51.4Extravasation Is Recognised and Managed Immediately
• 51.5Multidisciplinary Tumour Board Informs Treatment Planning
• 51.6Palliative Care Integrated Alongside Active Treatment
• 51.7High-Alert Medicines Have Extra Safeguards
• 51.8Patients Are Triaged by Urgency
• 51.9Sepsis Is Recognised and Treated Quickly
• 51.10Pain and Symptoms Are Assessed and Controlled
• 51.11The Patient’s Goals and Wishes Are Recorded

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• 52.1Suicide Risk Screening and Continuous Observation for High-Risk Patients
• 52.2Environmental Ligature Risk Is Identified and Mitigated
• 52.3Restraint and Seclusion Used as Last Resort, With Strict Documentation
• 52.4Psychiatric Medication Management Follows a Defined Interaction and Monitoring Protocol
• 52.5Staff Are Trained and Drilled in De-escalation, Not Only Briefed
• 52.6Discharge Safety Planning With Follow-Up Care Arranged

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• 22.1Resident and Trainee Supervision With Verified, Graduated Autonomy
• 22.2Patients Are Informed of Trainee Involvement in Their Care
• 22.3Research Activity Operates Under Independent Ethics Review Before Enrolment
• 22.4Clinical Care and Research Participation Are Clearly Separated in Consent
• 22.5Conflicts of Interest Between Research and Clinical Care Are Disclosed and Managed
• 22.6Teaching Faculty Maintain Verified, Current Clinical Competency

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• 23.1Governance Structure Defines Authority Between Central and Site-Level Leadership
• 23.2Incident Learning Is Shared Across Sites, Not Siloed
• 23.3Clinical Policy Is Standardised Across Sites, With Any Local Variation Explicitly Justified
• 23.4Credentialing and Privileging Are Centrally Verified and Consistently Recognised
• 23.5Central Resource and
• 23.6Site-Level Quality Data Is Reviewed by Central Governance

Open Standard 18 page ›

• 24.1Pricing Transparency for International Patients
• 24.2Remote Records Transfer to Home-Country Physician
• 24.3Language Access for Foreign Patients
• 24.4Travel, Accommodation, and Logistics Coordination
• 24.5Post-Return Complication Tracking
• 24.6Travel Documentation Support for International Patients
• 24.7International Patient Complaint and Redress Process
• 24.8Facilitator and Agent Verification
• 24.9Travel-Associated Infection Risk Protocol
• 24.10Post-Procedure Travel Timing and Venous Thromboembolism Risk

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• 25.1People-Centred Care Adapted to Migration and Displacement Experience
• 25.2Supporting Patient Agency Through Understanding of Care and the Health System
• 25.3Language and Communication Aids: Interpreters and Cultural Mediators
• 25.4Collaborative Practice Across Health and Social Services
• 25.5Surge Capacity for Migration-Related Demand
• 25.6Evidence-Informed Care for Refugee and Migrant Populations
• 25.7Staff Reflective Practice, Bias Awareness, and Self-Care in Migration Contexts
• 25.8Cross-Border Continuity of Care
• 25.9Camp-Based and Non-Camp Service Model Fit
• 25.10Legal Status Diversity Recognition

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• 26.1Dialysis Water Is Treated and Tested to a Documented
• 26.2Water Treatment Equipment Is Maintained and Monitored Online
• 26.3Dialysis Fluid and Concentrates Are Prepared to a Documented Procedure
• 26.4Dialysers Are Reprocessed Safely, Traced, and Used Only Where Permitted
• 26.5Each Treatment Is Prescribed, and Its Adequacy Is Monitored
• 26.6Vascular Access Is Assessed, Protected and Its Infections Tracked
• 26.7Dialysis Machines Are Checked Before Each Session
• 26.8Emergency Response During Dialysis Is Ready
• 26.9Infection Prevention Across the Dialysis Unit
• 26.10Patients Are Informed About Their Dialysis Choices
• 26.11Staffing and Competence for Dialysis Are Defined
• 26.12Dialysis Outcomes and Incidents Are Reviewed

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• 27.1The Service Never Disadvantages a Patient Who Cannot Access It Digitally
• 27.2AI Systems Are Introduced in Line With WHO AI Governance Guidance
• 27.3AI Systems Are Monitored for Unintended Consequences
• 27.4Clinicians Are Consulted Before an AI System Is Introduced
• 27.5Accountability for AI-Assisted Care Is Explicitly Defined
• 27.6Providers Have Access to Ongoing Education and Peer Connection
• 27.7Clinician Wellbeing and Isolation Risk Are Monitored
• 27.8Digital Infrastructure Impact Is Assessed, Not Assumed Negligible
• 27.9Hosting and Technology Procurement Considers Environmental Impact
• 27.10The Provider Considers Its Reduction of Patient Travel Impact
• 27.11Staff Are Engaged in Sustainability Practice
• 27.12Sustainability Commitments Are Reviewed, Not Static
• 27.13Patient Identity Is Confirmed at Every Remote Consultation
• 27.14Informed Consent for Remote Care Is Recorded
• 27.15Prescribing at a Distance Follows a Safe Process
• 27.16Clinical Records From Remote Consultations Are Complete
• 27.17Technical Failure During a Consultation Has a Safe Route

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• 28.1Individualised Functional Maintenance Plan Based on Assessment
• 28.2Coordination Between Therapy and Daily Nursing Care
• 28.3Resident and Family Goal-Setting
• 28.4Function Tracked With Validated Tools, Decline Flagged Early
• 28.5Equipment and Assistive Device Provision Matches Need
• 28.6Restraint-Free and Least-Restrictive Mobility Support
• 28.7Environmental Impact Is Assessed Across a 24-Hour Operation
• 28.8Clinical and Incontinence Waste Is Segregated and Responsibly Disposed
• 28.9Procurement Considers Environmental Impact
• 28.10Energy and Water Use Are Monitored and Reduced Where Possible
• 28.11Residents, Families, and
• 28.12The Facility Plans for Climate-Related Risk to Resident Safety
• 28.13Sustainability Commitments Are Reviewed, Not Static
• 28.14Digital Systems Are Evaluated Before Adoption
• 28.15Digital Care Never Disadvantages a Resident or Family Who Cannot Use It
• 28.16Technical Support Is Available for Digital Systems
• 28.17AI Systems Are Introduced in Line With WHO AI Governance Guidance
• 28.18AI Systems Are Monitored for Unintended Consequences
• 28.19Staff Are Consulted Before an AI System Is Introduced
• 28.20Accountability for AI-Assisted Care Is Explicitly Defined
• 28.21Residents and Families Are Informed When Care Involves AI
• 28.22Every Member of the Workforce Is Credentialed for Their Actual Role
• 28.23Workforce Health and Safety Is Protected, Including Manual Handling
• 28.24Staff Are Protected From Resident and Family Aggression
• 28.25End-of-Life and Palliative Care Is Planned With the Resident
• 28.26Advance Care Planning Is Discussed and Recorded
• 28.27Death of a Resident Is Handled With Dignity and Learning

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• 29.1The Client’s Home Remains Theirs to Control
• 29.2A Written Statement of Rights Is Provided and Understood
• 29.3The Client Can Request a Caregiver Replacement
• 29.4A Reachable Alternate Contact Exists Beyond the Caregiver Themselves
• 29.5Freedom From Abuse and Neglect Is Actively Verified
• 29.6Background Screening Uses Verified Identity, Not Name-Based Matching Alone
• 29.7Abuse Registries Are Checked in Every Country the Caregiver Has Worked
• 29.8Any Care-Worker Exclusion Registry Is Specifically Checked
• 29.9Screening Is Repeated Periodically
• 29.10A Disqualifying Finding Triggers Individualised Assessment
• 29.11A Structured Home Safety Assessment Occurs Before Care Begins
• 29.12Identified Hazards Lead to Tracked Remediation
• 29.13A Fall Triggers Reassessment
• 29.14The Home Environment Is Reassessed Periodically
• 29.15Emergency Access to the Home Is Confirmed
• 29.16Medication Reminders and Administration Are Distinguished
• 29.17A Single, Current Medication List Is Shared Across Everyone Involved
• 29.18A Medication Change or Care
• 29.19Medications Belonging to Different Household Members Are Distinguished and Secured
• 29.20A Missed or Uncertain Dose Is Actively Followed Up
• 29.21A Risk Assessment of the Home Occurs Before the First Visit
• 29.22A Workplace Violence Prevention Programme Exists, Adapted for the Home Setting
• 29.23The Caregiver Has a Way to Signal Distress Discreetly
• 29.24Hostile Animals and Environmental Hazards Are Specifically Assessed
• 29.25Near-Misses Are Actively Reported and Used to Update Risk Assessments
• 29.26Supervisory Visits Occur On-Site
• 29.27Personal Care Supervision Includes Observing the Aide Providing Care
• 29.28Supervision Documentation Captures Objective, Measurable Observations
• 29.29A Change in Client Needs Triggers Care Plan Review
• 29.30An Identified Deficiency Leads to Retraining and Re-Evaluation
• 29.31A Coverage Plan Exists for a Solo Caregiver’s Absence
• 29.32Caregiver Continuity Is Actively Tracked and Prioritised for High-Need Clients
• 29.33New Caregiver Retention Receives Structured Attention in the First 100 Days
• 29.34Caregiver Isolation Is Addressed Through Regular Supervisor Contact
• 29.35Incident Reporting Accounts for Detection Delay in an Unsupervised Setting
• 29.36Care Is Adapted to a Client’s Migration and Displacement Experience
• 29.37Language Support Accounts for Persistent, Daily Interaction
• 29.38Cultural and Religious Practices in the Client’s Home Are Respected
• 29.39Caregiver Work Authorisation Is Verified Through Legal, Non-Discriminatory Practice
• 29.40A Caregiver’s Legal Status Change Is Handled With Support
• 29.41Immigrant Caregivers’ Retention Advantage Is Recognised and Supported
• 29.42Legal Status Diversity Recognition for Clients
• 29.43Care Is Documented and Provided to Clients Regardless of Immigration or Legal Status
• 29.44Staff Reflective Practice and Bias Awareness Extends to How Immigrant Caregivers Are Treated
• 29.45Continuity Across a Client’s Relocation Is Actively Supported

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• 30.1Biometric and Health-Tracking Data Is Protected and Appropriately Used
• 30.2Medical Clearance Required Before Post-Injury Programming
• 30.3Qualified
• 30.4Individualised Programme Based on Functional Assessment
• 30.5Pain and Warning Sign Recognition, With a Stop Protocol
• 30.6Communication With Referring Clinician Where Applicable
• 30.7Pre-Participation Screening Is Completed Before Exercise
• 30.8Exercise Is Supervised and Instructed by Qualified
• 30.9Exercise Equipment Is Safe, Maintained and Correctly Set Up
• 30.10Cardiac and Medical Emergencies Are Planned For
• 30.11Members Are Informed of Risks and Give Consent

Open Standard 25 page ›

• 31.1Reusable Instruments Are Sterilised by a Validated Process
• 31.2Sterilisation Is Monitored and the Monitoring Is Recorded
• 31.3Instrument Processing Follows One-Way Flow
• 31.4Single-Use Items Are Never Reused
• 31.5Dental Unit Waterlines Are Managed and Tested
• 31.6Between-Patient Turnover of the Dental Chair Is Documented
• 31.7Aerosol and Splatter Are Controlled
• 31.8Dental Radiography Is Justified and Dose-Optimised
• 31.9Radiation Protection Programme Is Documented
• 31.10Dental Amalgam Waste Is Handled to Prevent Mercury Release
• 31.11Sharps and Dental Clinical Waste Are Segregated
• 31.12Emergency Equipment Is Available and Checked
• 31.13Staff Are Trained in Dental Medical Emergencies
• 31.14Local Anaesthetic Doses Are Calculated and Recorded
• 31.15Sedation Is Offered Only with Competence and Monitoring
• 31.16Minor Oral Surgery Is Assessed, Consented and Followed Up
• 31.17Dental Records Use
• 31.18Consent Is Obtained Before Each Procedure
• 31.19Fees Are Transparent and Shown Before Treatment
• 31.20Implants and Prosthetic Components Are Traceable
• 31.21Dental Laboratory Work Is Specified, Traceable and Disinfected
• 31.22Clinicians Hold Current Licences and Competence
• 31.23Children and People with Special Needs Are Cared For Safely
• 31.24Referral to Other Specialists Is Documented
• 31.25Oral Health Education Is Given and Recorded

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• 32.1Practitioners Are Qualified for Each Procedure They Perform
• 32.2Consent Reflects Realistic Outcomes and Allows Time to Reconsider
• 32.3Pre-Procedure Assessment Identifies Contraindications
• 32.4Sedation and Anaesthesia Are Safe
• 32.5Advertising and Claims Are Accurate
• 32.6Follow-Up and Complications Are Managed

Open Standard 27 page ›

• 33.1Calibration Current and Traceable to a Reference
• 33.2Reagent Lots Verified Before Use
• 33.3Method Validated Before Clinical Use
• 33.4Internal Quality Control Run Before Results Are Released
• 33.5External Quality Assessment Participation
• 33.6Test Indications, Limitations and Patient Preparation Given to Users
• 33.7Specimens Accepted, Logged and Rejected by Defined Criteria
• 33.8Specimen Transport Preserves Integrity
• 33.9STAT Specimens Prioritised and Turnaround Monitored
• 33.10Chain of Custody for Forensic or Legal Specimens
• 33.11Critical Values Communicated and Receipt Verified
• 33.12Results Authorised Before Release
• 33.13Reports Meet a Defined Minimum and Reach the Correct Recipient
• 33.14Result Amendments Traceable to the Original
• 33.15Suppliers and Reagents Qualified

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• 36.1Every Arrival Is Triaged Before Waiting
• 36.2Resuscitation Area Is Always Ready
• 36.3A Senior Clinician Is Responsible at All Times
• 36.4Decisions to Admit, Transfer or Discharge Are Recorded and Handed Over
• 36.5Patients Who Leave Before Assessment Are Recorded and Followed Up

Open Standard 29 page ›

• 37.1Medicines Are Dosed for the Child’s Weight and Age
• 37.2Newborn Care Is Matched to a Defined Level of Care
• 37.3Families Are Informed and Present in Care
• 37.4Children Are Protected From Harm
• 37.5Newborns Are Transferred Safely to a Higher Level of Care

Open Standard 30 page ›

• 38.1Substance Use Is Assessed With a Validated Tool
• 38.2Treatment Is Individual and Prescribed by a Licensed Clinician
• 38.3Harm Reduction Is Available
• 38.4Information About Use Is Confidential
• 38.5Discharge Is Planned With Links to Community Support

Open Standard 31 page ›

• 39.1Needs Are Assessed Before Services Start
• 39.2Every Deployment Has a Defined Exit or Handover
• 39.3Protection and Do-No-Harm Apply to Every Activity
• 39.4A Mass-Casualty Plan Is Written and Tested
• 39.5Staff Security and Wellbeing Are Managed

Open Standard 32 page ›

• 40.1Nutrition Care Is Provided by a Qualified Dietitian or Trained Clinician
• 40.2Each Patient Has an Individual Nutrition Plan
• 40.3Malnutrition Is Identified, Monitored and Treated
• 40.4Diets and Texture Are Matched to the Swallowing Assessment
• 40.5Food Service Is Safe and Hygienic

Open Standard 33 page ›

• 41.1Practitioners Are Qualified and Registered
• 41.2Patients Are Told What Is and Is Not Supported by Evidence
• 41.3Conventional Care Is Not Replaced When It Is Needed
• 41.4Products Are Safe, Sourced, Labelled and Not Misleading
• 41.5Adverse Events Are Recorded and Reviewed

Open Standard 34 page ›

• 42.1The Discharge Plan Is Written and Passed On
• 42.2Follow-Up Is Booked Before the Patient Leaves
• 42.3High-Risk Patients Are Contacted After Discharge
• 42.4Patients Know When and How to Seek Urgent Help
• 42.5Readmissions and Aftercare Problems Are Reviewed
• 42.6Patients Can Complain After Leaving, and Complaints Are Answered

Open Standard 35 page ›

• 44.1Patients Can Find the Service Before They Arrive
• 44.2The Emergency Entrance Is Clearly Marked and Open
• 44.3Signs Work for People With Limited Literacy or Sight
• 44.4The Route to Key Services Is Marked and Tested
• 44.5Access Information Is Kept Current Through Change

Open Standard 36 page ›

• 45.1Waiting Times Are Measured and Shared
• 45.2Patients in Urgent Need Are Not Left Unseen
• 45.3Waiting Patients Are Kept Informed
• 45.4Health Information Is in Plain Language
• 45.5Patients Can Ask

Open Standard 37 page ›

• 46.1A Hospital Disaster Plan Is Written and Owned
• 46.2Hazards Are Assessed, Including Climate and Utilities
• 46.3Essential Services Continue When Utilities Fail
• 46.4Staff Are Trained and Drills Are Held
• 46.5The Plan Is Reviewed After Each Activation

Open Standard 38 page ›

• 47.1Deterioration Is Detected With a Recognised Score
• 47.2Sepsis Is Recognised and Treated Within a Defined Time
• 47.3Venous Thromboembolism Risk Is Assessed on Admission
• 47.4Patients on Anticoagulants Are Monitored and Their Reversal Is Planned
• 47.5Deterioration and Sepsis Events Are Reviewed

Open Standard 39 page ›

• 48.1Falls Risk Is Assessed and Acted On
• 48.2Pressure Injury Is Prevented in Patients at Risk
• 48.3Pressure Injuries Are Staged, Treated and Recorded
• 48.4Structured Handover Is Used at Every Transfer of Care
• 48.5Falls, Pressure Injury and Handover Events Are Reviewed

Open Standard 40 page ›

• 49.1Patients Are Asked About Their Wishes for Future Care
• 49.2Advance Directives Are Recognised and Followed Where Permitted
• 49.3Palliative Needs Are Identified and Met
• 49.4Dignity Is Protected in Every Interaction
• 49.5Staff Are Trained in Dignity and Communication

Open Standard 41 page ›

• 42.1Each Segment Has a Named Accountable Party
• 42.2The End of the Provider’s Responsibility Is Written Down
• 42.3The Receiving Facility or Service Accepts the Patient Before Departure
• 42.4The Transfer Plan Is Written Before Departure, With a Back-Up Plan
• 42.5Pre-Transport Clinical Assessment Completed
• 42.6Transfer Level Matches Patient Need
• 42.7Critically Ill Patients Transported With Matched
• 42.8Neonatal and Paediatric Transfers Use Specialist Arrangements
• 42.9Air Transport Is Planned, Authorised and Controlled
• 42.10Patient Consent Obtained and Documented
• 42.11Crew Scope of Practice Matches Transfer Acuity
• 42.12Minimum Crew Complement Written and Applied
• 42.13Escort Doctor Qualified and Credentialed for the Transfer Type
• 42.14Escort Continuity to the Handover Point
• 42.15Certification Current Before Each Shift
• 42.16Driver Training Specific to Patient Transport
• 42.17Fatigue Management for Long-Distance Transfers
• 42.18Vehicle Maintenance Current and Documented
• 42.19Medical Equipment Checked and Calibrated
• 42.20Medication Storage Meets Requirements
• 42.21Vehicle Safety Equipment Present and Functional
• 42.22Aircraft and Cabin Equipment Suitable for the Patient
• 42.23Commercial Flight: Seats, Equipment and Airline Acceptance Arranged in Advance
• 42.24Airport and Ground Segments Are Part of the Same Plan
• 42.25Continuous Monitoring Appropriate to Acuity
• 42.26Deterioration Recognition and Response
• 42.27Cardiac Arrest and Life-Threatening Event Protocol
• 42.28Diversion to the Nearest Appropriate Facility
• 42.29Breakdown or Accident Contingency
• 42.30Mass Casualty and Surge Plan
• 42.31Real-Time Status Communication to Dispatch
• 42.32Structured Handover at Pickup
• 42.33Structured Handover at Destination and at Every Segment Change
• 42.34Written Documentation Travels With the Patient
• 42.35Cross-Border Records and Data Transfer
• 42.36Vehicle Cleaned and Disinfected Between Patients
• 42.37Personal Protective Equipment Available and Used
• 42.38Isolation and Transmission-Risk Protocol
• 42.39Sharps and Biohazard Waste Disposal
• 42.40Crew Exposure Incident Response
• 42.41Language-Appropriate Communication With the Patient
• 42.42Escort Clinicians Recognised in the Receiving Country
• 42.43Import of Medicines and Equipment Across Borders
• 42.44Insurance and Liability for the Chain
• 42.45Post-Incident Debrief
• 42.46Dispatch Decision Rule and Right to Refuse

Open Standard 42 page ›

• 5.1Donors Are Selected and Screened
• 5.2Each Donation Is Tested
• 5.3Each Donation Is Traceable
• 5.4Storage and Transport Keep Products Within Their Conditions
• 5.5Issuing Blood Is Checked
• 5.6Staff Are Qualified
• 5.7Adverse Reactions Are Investigated
• 5.8Quality Management Is in Place
• 5.9Emergency Release Follows a Written Procedure

Open Standard 43 page ›

• 6.1Patients Are Selected for Same-Day Surgery
• 6.2Anaesthesia and Sedation Are Given by Trained
• 6.3Recovery Is Monitored Until Discharge Criteria Are Met
• 6.4Each Patient Goes Home With an Adult Escort and Advice
• 6.5Theatre Safety Checks Are Done
• 6.6Surgical Site Infections Are Tracked
• 6.7Unplanned Admissions Are Reviewed
• 6.8Anaesthesia Is Delivered Safely
• 6.9The Surgical Safety Checklist Is Used
• 6.10Surgical Site Infection Is Actively Prevented

Open Standard 44 page ›

• 7.1Calls Are Answered Within a Set Time
• 7.2Calls Are Triaged by Clinical Priority
• 7.3Resources Are Dispatched Within a Set Time
• 7.4Staff Are Trained for Call Handling
• 7.5Each Call Is Recorded
• 7.6System Resilience Is Planned
• 7.7Calls Are Reviewed
• 7.8Waiting Calls Are Re-Prioritised and Escalated
• 7.9A Clinical Supervisor Is Available to Call Takers
• 7.10The end of the provider’s responsibility is written down
• 7.11Dispatch decision rule and right to refuse

Open Standard 45 page ›

• 8.1Patients Receive Clear Information on Treatment
• 8.2Consent Is Specific to Each Stage
• 8.3Gametes and Embryos Are Identified and Traced
• 8.4Storage Is Secure and Monitored
• 8.5Screening and Donor Checks Are Done
• 8.6Staff Are Qualified
• 8.7Adverse Events and Outcomes Are Reviewed
• 8.8Psychological Support Is Offered
• 8.9A Written Plan Responds to a Gamete or Embryo Mix-Up
• 8.10Prices Are Disclosed Before Treatment Begins
• 8.11Organ and Tissue Traceability, End to End

Open Standard 46 page ›

• 9.1The Unit Is Set Up to a Minimum Safe
• 9.2Triage Works Under Pressure
• 9.3Surgical Safety Is Maintained Under Constraint
• 9.4Blood and Medicines Are Managed Under Constraint
• 9.5Referral and Evacuation Routes Are Defined
• 9.6Staff Are Qualified and Supervised
• 9.7Records Are Kept Under Constraint
• 9.8Infection Control and Outbreak Response Are in Place
• 9.9Protection of Patients and
• 9.10Mental Health and Psychosocial Support Are Offered
• 9.11Handover to Permanent Services Is Planned
• 9.12Donated Medicines and Equipment Are Checked Before Use
• 9.13Patients Who Report Sexual Violence Receive a Defined Clinical Response
• 9.14Patients Are Triaged by Urgency
• 9.15A Mass-Casualty and Utility-Failure Plan Exists and Is Rehearsed
• 9.16The Surgical Safety Checklist Is Used
• 9.17Anaesthesia Is Delivered Safely
• 9.18Surgical Site Infection Is Actively Prevented
• 9.19Blood Is Verified Before Every Transfusion
• 9.20The transfer plan is written before departure, with a back-up plan
• 9.21Dispatch decision rule and right to refuse
• 9.22Violence Against
• 9.23Vulnerable Patients Have Specific Protections

Open Standard 47 page ›

• 10.1Pain and Symptoms Are Assessed and Controlled
• 10.2Opioids and Controlled Medicines Are Managed Safely
• 10.3The Patient’s Goals and Wishes Are Recorded
• 10.4Family and Carers Are Supported
• 10.5Spiritual, Cultural and Psychological Needs Are Addressed
• 10.6Dying Patients Are Cared for With Dignity
• 10.7Staff Are Trained in Palliative Care
• 10.8Bereavement Follow-Up Is Offered
• 10.9Service Quality Is Reviewed
• 10.10Out-of-Hours Symptom Advice Is Available
• 10.11Treatment Limits Are Visible at the Point of Care

Open Standard 48 page ›

• 11.1Each Patient Is Assessed Before the Procedure
• 11.2Products and Medicines Are Verified and Stored Correctly
• 11.3The Practitioner Is Trained for Each Procedure
• 11.4Consent Covers Risks and Complications
• 11.5Complications Are Managed Through a Defined Pathway
• 11.6Emergency Response Is Ready
• 11.7Sterile Technique and Infection Control Are Practised
• 11.8Follow-Up Is Arranged
• 11.9Product Recalls and Adverse Reactions Are Acted On

Open Standard 49 page ›

• 12.1Antenatal Care Follows a Schedule
• 12.2Birth Is Attended by Trained
• 12.3Emergency Obstetric Response Is Ready
• 12.4Blood Is Available for Obstetric Emergencies
• 12.5Neonatal Care Is Available
• 12.6Postnatal Care Is Provided
• 12.7Women Are Informed and Involved in Choices
• 12.8Maternal and Perinatal Outcomes Are Reviewed
• 12.9Mother and Newborn Are Identified Together
• 12.10Deterioration After Birth Is Recognised With an Early-Warning Tool
• 12.11Gynaecological Problems Are Assessed Through a Defined Pathway
• 12.12Contraception and Reproductive Choice Are Offered
• 12.13Cervical and Breast Screening Is Offered and Followed Up
• 12.14Care After Pregnancy Loss Is Provided With Support
• 12.15Deteriorating Patients Are Recognised Early

Open Standard 50 page ›

• 13.1Each Site Is Assessed Before Use
• 13.2The Unit Carries the Equipment It Needs
• 13.3Emergency Transfer Is Planned
• 13.4Records Are Kept and Brought Back
• 13.5Staff Are Trained for the Setting
• 13.6Consent and Privacy Are Respected in the Community
• 13.7Follow-Up Is Arranged
• 13.8Coverage Is Reviewed
• 13.9The Vehicle Is Roadworthy and Equipped
• 13.10Lone Working Has a Check-In and a Response

Open Standard 51 page ›

• 14.1Assessments Are Clinically Sound and Confidential
• 14.2Staff Are Qualified for the Assessments They Make
• 14.3Health Surveillance Follows a Schedule
• 14.4Concerns Are Reported to the Employer in Line With International Guidance
• 14.5Workplace Advice Is Given
• 14.6Return-to-Work Plans Are Made
• 14.7Assessors Are Free of Conflicting Roles
• 14.8Workers Can See Outcomes and Ask for Review

Open Standard 52 page ›

• 15.1Eye and Hearing Examinations Are Clinically Sound
• 15.2Staff Are Qualified for the Service They Give
• 15.3Products Are Fitted and Checked
• 15.4Contact Lens and Hearing Aid Hygiene Is Taught
• 15.5Aftercare and Follow-Up Are Arranged
• 15.6Complaints About Products Are Recorded and Acted On
• 15.7Urgent Eye and Ear Findings Are Referred the Same Day

Open Standard 53 page ›

• 16.1Care Is Appropriate to Children’s Age and Size
• 16.2Consent Is Obtained From a Parent or Guardian
• 16.3Child Safeguarding Is in Place
• 16.4Families Are Involved and Supported
• 16.5The Environment Is Child-Friendly and Safe
• 16.6Staff Are Trained in Paediatric Care
• 16.7Immunisation and Child Health Checks Are Provided
• 16.8Children Are Transferred Safely
• 16.9Child Health Outcomes Are Reviewed
• 16.10Emergency Equipment and Weight-Based Dose References Are Available
• 16.11Weight Is Recorded at Each Contact Before a Dose Is Calculated
• 16.12Neonatal and Paediatric Transfers Use Specialist Arrangements

Open Standard 54 page ›

• 17.1Each Prescription Is Checked Before Dispensing
• 17.2Counselling Is Given
• 17.3A Qualified Pharmacist Is Accountable
• 17.4Dispensing Errors Are Recorded and Reviewed
• 17.5Controlled Medicines Are Recorded
• 17.6Medicines Are Stored Securely and Correctly
• 17.7Medicine Supply Is Managed
• 17.8Medicines Are Recalled When Needed
• 17.9Medicines Are Bought From Licensed Sources
• 17.10Medicines Are Stored and Given Safely

Open Standard 55 page ›

• 18.1Each Patient Has a Clinical Assessment Before Treatment
• 18.2Treatment Is Delivered by Trained
• 18.3Treatment Is Based on Current Evidence
• 18.4Progress Is Measured Against the Goals
• 18.5Equipment Is Safe and Checked
• 18.6Patients Are Given Advice to Continue at Home
• 18.7Outcomes Are Reviewed

Open Standard 56 page ›

• 19.1Each Specimen Is Correctly Identified at Collection
• 19.2Collection Is Done Correctly
• 19.3Sharps and Waste Are Handled Safely
• 19.4Specimens Are Transported Safely and on Time
• 19.5Refused or Unsuitable Specimens Are Recorded
• 19.6Staff Are Trained
• 19.7Results Reach the Requester
• 19.8Consent or Refusal for Collection Is Recorded

Open Standard 57 page ›

• 20.1Each Athlete Has a Clinical Assessment
• 20.2Return-to-Sport Decisions Are Staged and Documented
• 20.3Pre-Participation Checks Are Done Where Required
• 20.4Staff Are Qualified for the Care They Give
• 20.5Emergency Response for Sports Events Is Planned
• 20.6Anti-Doping and Medicines Are Handled Correctly
• 20.7Training Load and Injury Are Reviewed
• 20.8Suspected Head Injury Removes the Athlete From Play

Open Standard 58 page ›

• 21.1Patients Are Triaged on Arrival
• 21.2The Service Has Defined Limits
• 21.3Emergency Response Is Ready
• 21.4Waiting Times Are Measured and Acted On
• 21.5Patients Are Given Follow-Up Advice
• 21.6Attendance Patterns Are Reviewed
• 21.7Patients Waiting to Be Seen Are Re-Checked
• 21.8Patients Can Find the Clinic and Its Services Before Arriving
• 21.9Emergency Equipment and Drugs Are Ready

Open Standard 59 page ›

• 53.1Allergy History Is Taken and Recorded
• 53.2Anaphylaxis Is Recognised and Treated at Once
• 53.3Allergen Testing Is Quality-Controlled and Interpreted by a Clinician
• 53.4Allergen Immunotherapy Follows a Written Protocol
• 53.5Allergy Results Are Communicated and Acted On

Open Standard 60 page ›

• 54.1Skin Lesions Are Examined and Suspicious Lesions Referred
• 54.2Skin Procedures Are Done With Sterile Technique
• 54.3Laser and Light Devices Are Operated Safely
• 54.4Systemic Dermatology Drugs Are Monitored
• 54.5Patients Leave With Written Aftercare and a Booked Follow-Up

Open Standard 61 page ›

• 55.1Patients Are Assessed for Suitability and Realistic Expectations
• 55.2Consent Is Informed, Realistic and Given Without Pressure
• 55.3Anaesthesia and Sedation Are Given by Credentialed
• 55.4The Surgical Safety Checklist and Infection Bundle Are Used
• 55.5Recovery, Discharge and Follow-Up Are Planned

Open Standard 62 page ›

• 56.1Cardiac Risk Is Assessed Before Investigation or Procedure
• 56.2Cardiac Procedures Follow a Defined Safety
• 56.3Defibrillators and Emergency Equipment Are Checked Daily
• 56.4Antithrombotic Therapy Is Managed Under a Written Plan
• 56.5Cardiac Patients Leave With a Follow-Up and Risk Reduction Plan

Open Standard 63 page ›

• 57.1The Radiotherapy Plan Is Justified and Independently Checked Before the First Treatment
• 57.2Patient Identity and Treatment Site Are Verified Before Every Fraction
• 57.3Treatment Equipment Is Checked by a Quality Assurance Programme
• 57.4Staff and Visitors Are Protected by Shielding, Controlled Areas and Dosimetry
• 57.5Patients Receive Written Information on Side Effects and Follow-Up

Open Standard 64 page ›

• 58.1Every Inpatient Has an Admission Assessment and a Daily Review
• 58.2Medicines Are Reconciled and Given Safely on the Ward
• 58.3Deterioration Is Recognised and Escalated Without Delay
• 58.4Falls, Pressure Injuries and Infections Are Prevented on the Ward
• 58.5Discharge Is Planned and Handed Over Safely

Open Standard 65 page ›

• 59.1Specialist Referrals Are Triaged and Tracked to an Appointment
• 59.2Specialist Consultations Are Assessed, Consented and Within the Clinician Scope
• 59.3Results Are Communicated and Missing Results Are Followed Up
• 59.4Medicines Are Reviewed at Each Visit and Language Access Is Provided
• 59.5Follow-Up and Recall Are Planned for Every Patient

Open Standard 66 page ›

• 60.1Surgeons Operate Only Within Their Granted Privileges
• 60.2The Surgical Safety Checklist and Site Marking Are Used for Every Operation
• 60.3Anaesthesia and Sedation Are Given With Monitoring and Emergency Equipment
• 60.4Surgical Site Infection and Thrombosis Are Prevented
• 60.5Patients Recover, Are Discharged and Are Followed Up Safely
• 60.6The Surgical Safety Checklist Is Used
• 60.7Anaesthesia Is Delivered Safely
• 60.8Surgical Site Infection Is Actively Prevented

Open Standard 67 page ›

• 61.1Each Patient at Risk of a Fall Has an Individual Prevention Plan in Use
• 61.2The Environment and Equipment Are Checked for Falls Hazards
• 61.3Every Fall Is Reported, the Patient Is Checked and the Event Is Reviewed
• 61.4Staff Are Trained in Falls Prevention
• 61.5Falls Data Are Reviewed at Set Intervals and Used to Change Practice

Open Standard 68 page ›

• 62.1Every Person Entering Custody Has a Health Screening and Medical Examination
• 62.2People in Custody Receive Care of the Same Quality as in the Community
• 62.3Medical Confidentiality Is Protected
• 62.4Health
• 62.5Mental Health, Self-Harm, Infection and Hospital Transfer Are Managed Under Written Procedures

Open Standard 69 page ›

• 63.1Every Handover Between Clinicians Uses a Structured Method
• 63.2Each Handover Covers the Key Information and the Receiver Confirms It
• 63.3Deteriorating and High-Risk Patients Are Handed Over With Escalation Status
• 63.4Patients Moved Between Wards or Facilities Travel With a Written Handover
• 63.5Handover Is Audited and Failures Are Reviewed

Open Standard 70 page ›