Standards › ASF Health Standards Version 11 › Standard 9
Standard 9
Environment and Accessibility
The physical environment supports safe movement, access and rescue for every patient. Handrails, toilets, lighting, beds, mobility equipment and clear routes reduce falls, and doors and exits allow rescue in an emergency.
How to read the colours
Red: Must. Required in every setting. Criteria that protect life are always red.
Green: Medium. Required, adapted to what a humanitarian or transition setting can realistically do.
Yellow: Minimum. The lowest acceptable level in a humanitarian setting, where resources are very limited.
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Every policy, SOP, form, checklist and course on this page is a draft to help you. Adapt it to your facility, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how.
9.1Handrails Are Fitted Where Patients WalkHumanitarian settings: MediumTransition and fragile: MediumStandard: Must
Handrails are fitted on both sides of corridors and stairs that patients use unaided, at a height and grip suitable for adults and children, and checked regularly for firm fixing.
Why it matters. Patients who are unsteady, frail or recovering from illness use handrails to keep their balance. Missing or loose handrails are a common cause of falls.
Questions the surveyor asks
- Are handrails fitted on the routes patients walk? Corridors, stairs and ramps used by patients.
- Are the handrails firmly fixed and at a usable height? A loose or too-high rail gives no support.
- Is the condition of the handrails checked? A recorded check, not an occasional look.
How the surveyor verifies this criterion
Sample. A walk of the main patient routes with the maintenance check record for the last 6 months.
1. Handrails are fitted
Method. Walk each patient route and note where a handrail is missing.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. Handrails are fitted on both sides of stairs and on every corridor used by unaided patients.
2. Handrails are firmly fixed
Method. Test each rail by hand at several points.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. No rail moves when pulled, and each one is at a height usable by an adult.
3. Checks are recorded
Method. Check the maintenance log for the last 6 months.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. A check is recorded at least every 6 months, and defects are repaired.
Good practice. Handrails on every patient route, firmly fixed and checked regularly.
Immediate fail (any one means the criterion is not met). Patient routes have no handrails where patients walk unaided.
Partial because. Handrails are fitted but some are loose, or the checks are not recorded.
Staff, training and documents
Documents
- Falls environment checklist ward, bathroom, corridor (ASF-TOOL-FP-02)
- ENV-FRM-002 Cleanliness audit record
E-learning
- Slip, Trip & Fall Prevention (Must for all staff)
- Facility induction (Must for all staff)
9.2Toilets and Washrooms Have Correct Grab BarsHumanitarian settings: MediumTransition and fragile: MediumStandard: Must
Toilets and washrooms have grab bars beside the toilet and in the shower or bath area, fixed to the wall and set at the height and position the patient needs.
Why it matters. Getting on and off a toilet is one of the most common times a patient falls. A correctly fixed grab bar gives the patient something to hold.
Questions the surveyor asks
- Does each toilet have a grab bar beside it? One bar on the side the patient uses to rise is the minimum.
- Are the bars fixed securely to the wall? A bar that moves under load is worse than none.
- Is there a bar in the shower or bath area? Wet surfaces make the risk higher.
How the surveyor verifies this criterion
Sample. Every toilet and washroom used by patients, plus the cleaning and maintenance records.
1. Grab bar beside each toilet
Method. Walk the washrooms and note the presence of a bar.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. Every patient toilet has a grab bar within reach.
2. Bars are fixed securely
Method. Pull each bar by hand.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. No bar moves under a firm pull.
3. Shower or bath area is covered
Method. Check the wet area for a bar and a non-slip surface.
Evidence to show. Cleaning of shared clinical and waiting areas (ENV-SOP-002).
Pass when. A bar is in place in each shower or bath area used by patients.
Good practice. Grab bars in every patient washroom, fixed securely, with a bar in the wet area.
Immediate fail (any one means the criterion is not met). Patient toilets have no grab bars at all.
Partial because. Bars are present but some are loose, or the wet area has none.
Staff, training and documents
Documents
- Falls environment checklist ward, bathroom, corridor (ASF-TOOL-FP-02)
- ENV-SOP-002 Cleaning of shared clinical and waiting areas
E-learning
- Slip, Trip & Fall Prevention (Must for all staff)
9.3An Accessible Toilet Is Available Where Patients Need OneHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
At least one toilet is accessible to a wheelchair user, with a clear floor space, a grab bar on each side and a door that opens wide enough. Where the facility serves patients who need one, the toilet is in a route they can reach.
Why it matters. Patients who use a wheelchair or walking frame cannot use a standard toilet. Without an accessible toilet they are unable to use the facility safely or with dignity.
Questions the surveyor asks
- Is there at least one accessible toilet? Where a facility sees patients who need one, at least one must exist.
- Is the route to it step-free and clear? A toilet no patient can reach does not meet the criterion.
- Is the space and fitting set for wheelchair use? Clear floor space, grab bars and a door that opens wide enough.
How the surveyor verifies this criterion
Sample. The accessible toilet, its route, and the accessibility check record for the last 3 months.
1. Accessible toilet exists
Method. Visit the facility and locate the accessible toilet.
Evidence to show. Accessibility check record (ENV-FRM-001).
Pass when. At least one accessible toilet is in place and marked as such.
2. Route is step-free
Method. Walk from the main entrance to the toilet.
Evidence to show. Accessible reception and registration points (ENV-SOP-001).
Pass when. The route has no steps and the doors open without a barrier.
3. Fittings suit a wheelchair user
Method. Measure the floor space and check the grab bars and door.
Evidence to show. Using mobility aids: wheelchairs and canes (ASF brochure).
Pass when. A wheelchair can turn inside the room, and a bar is fixed on each side of the toilet.
Good practice. An accessible toilet on a step-free route, fitted for wheelchair use and recorded in the accessibility check.
Immediate fail (any one means the criterion is not met). No accessible toilet exists in a facility that admits patients who need one.
Partial because. The toilet exists but the route or the fittings do not meet the criterion.
Staff, training and documents
Documents
- ENV-FRM-001 Accessibility check record (registration)
- ENV-SOP-001 Accessible reception and registration points
- Using mobility aids: wheelchairs and canes (ASF brochure)
E-learning
- Slip, Trip & Fall Prevention (Must for all staff)
9.4Toilet and Washroom Doors Allow RescueHumanitarian settings: MediumTransition and fragile: MediumStandard: Must
Washroom doors can be opened from the outside in an emergency, with no lock that only the user can release. Where a door has a lock, staff have a means of entry, and the door is included in the fire drill.
Why it matters. A patient who collapses behind a locked door can go unseen for a long time. Rescue depends on being able to open the door quickly.
Questions the surveyor asks
- Can a washroom door be opened from outside? A key or override that staff hold, not one held by one person only.
- Is the door included in the fire and emergency plan? Rescue routes cover the washrooms, not only the wards.
- Is the rescue practised? A drill that does not test the washroom doors leaves a gap.
How the surveyor verifies this criterion
Sample. The washroom doors, the key or override arrangements, and the fire drill record.
1. Door opens from outside
Method. Test each washroom door from outside.
Evidence to show. Fire safety and evacuation (EMG-SOP-001).
Pass when. Every door can be opened from outside without a special key.
2. Keys or overrides are held
Method. Check that staff have a key or override for each locked door.
Evidence to show. Unit security and evacuation plan (FLD-PLN-002).
Pass when. Staff on every shift hold a means of entry to each locked washroom.
3. Rescue is practised
Method. Check the fire drill record for a washroom rescue.
Evidence to show. Fire drill record (EMG-FRM-002).
Pass when. A drill in the last 12 months includes a washroom rescue.
Good practice. Washroom doors open from outside, with staff keys or overrides, and rescue practised in drills.
Immediate fail (any one means the criterion is not met). A washroom door can be opened only from inside, with no override.
Partial because. Doors open from outside, but staff have no key or the drill does not cover washrooms.
Staff, training and documents
Documents
- EMG-SOP-001 Fire safety and evacuation
- FLD-PLN-002 Unit security and evacuation plan
- EMG-FRM-002 Fire drill record
E-learning
- Emergency Preparedness and Fire Safety (Must for all staff)
- Safety & Emergency Preparedness (Must for all staff)
9.5Lighting Supports Safe MovementHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Corridors, stairs, washrooms and wards are lit enough for patients and staff to see steps, edges and obstacles, and lights are repaired promptly when they fail.
Why it matters. Poor lighting makes steps, edges and obstacles hard to see, especially at night. Most falls on a ward happen in low light or on the way to the toilet.
Questions the surveyor asks
- Are corridors and stairs well lit? Patients should see the next step without straining.
- Are washrooms and night routes lit? The walk to the toilet at night is a high-risk route.
- Are failed lights repaired promptly? A repair log shows the response.
How the surveyor verifies this criterion
Sample. The main routes at night, the washroom lighting, and the repair log for the last 6 months.
1. Routes are lit
Method. Walk the main routes at night and check for dark spots.
Evidence to show. Facility signage standard (ENV-SOP-003).
Pass when. No route has a dark spot that hides a step or an edge.
2. Washrooms and night routes are lit
Method. Check the lights in each washroom and along the night route.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. Each washroom and night route has working lighting.
3. Repairs are recorded
Method. Check the repair log for the last 6 months.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. Failed lights are repaired within a set time, and the repair is recorded.
Good practice. Routes and washrooms lit for safe walking at night, with failed lights repaired promptly.
Immediate fail (any one means the criterion is not met). Routes and washrooms are dark at night and no repairs are recorded.
Partial because. Lighting is in place, but failed lights are not repaired promptly.
Staff, training and documents
Documents
- ENV-SOP-003 Facility signage standard
- Falls environment checklist ward, bathroom, corridor (ASF-TOOL-FP-02)
- ENV-SOP-006 Energy use monitoring and reduction
E-learning
- Slip, Trip & Fall Prevention (Must for all staff)
9.6Beds and Chairs Are Set to Reduce Fall RiskHumanitarian settings: MediumTransition and fragile: MediumStandard: Must
Beds are set to a low height with brakes applied, and chairs have a stable base and the right height for the patient. Staff adjust the bed and chair for each patient who is at risk of falling.
Why it matters. A bed that is too high or a chair that tips is a common cause of falls when a patient gets up. Low beds and stable chairs reduce the impact of a fall.
Questions the surveyor asks
- Are beds set to the lowest safe height when a patient is at risk? The height is adjusted as part of the patient’s care plan.
- Are the bed brakes and chair bases checked? A moving bed or a tipping chair is an immediate hazard.
- Is the risk checked at admission and on change of condition? A patient whose risk changes needs a new setting.
How the surveyor verifies this criterion
Sample. Twenty bed and chair checks on the wards, and the falls risk assessments for the last 3 months.
1. Beds are set low with brakes on
Method. Check the bed height and brakes on each sampled bed.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. Each sampled bed is at its lowest safe height, with brakes on, for a patient at risk.
2. Chairs are stable and fit the patient
Method. Check each sampled chair for a stable base and the right height.
Evidence to show. Using mobility aids: wheelchairs and canes (ASF brochure).
Pass when. Each sampled chair is stable and at a height the patient can use.
3. Risk is reassessed
Method. Check the falls risk record for each sampled at-risk patient.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. The bed and chair settings are reviewed at admission and whenever the patient’s condition changes.
Good practice. Beds and chairs set to suit each patient, with brakes and bases checked and risk reviewed.
Immediate fail (any one means the criterion is not met). Beds and chairs are left at full height with no check for patients at risk.
Partial because. Settings are right at admission but not reviewed when the patient’s condition changes.
Staff, training and documents
Documents
- Falls environment checklist ward, bathroom, corridor (ASF-TOOL-FP-02)
- Using mobility aids: wheelchairs and canes (ASF brochure)
E-learning
- Slip, Trip & Fall Prevention (Must for nursing staff)
9.7Walking Aids and Mobility Equipment Are Available and CheckedHumanitarian settings: MediumTransition and fragile: MinimumStandard: Must
Walking aids, wheelchairs and other mobility equipment are available for patients who need them, sized correctly, and checked on a set schedule. Faulty equipment is taken out of use until repaired.
Why it matters. A walking aid that is broken, too tall or missing leaves a patient at risk of falling. Regular checks find problems before they cause harm.
Questions the surveyor asks
- Is mobility equipment available for patients who need it? Walking frames, canes and wheelchairs in working order.
- Is each item sized and fitted to the patient? An ill-fitting aid is as hazardous as a broken one.
- Is equipment checked on a schedule? A recorded check with faulty items removed.
How the surveyor verifies this criterion
Sample. The mobility equipment inventory, the check records for the last 6 months, and the patient fitting records.
1. Equipment is available
Method. Check the inventory against the patients who need it.
Evidence to show. Using mobility aids: wheelchairs and canes (ASF brochure).
Pass when. Each patient who needs an aid has one available.
2. Equipment is fitted correctly
Method. Check the fitting record for a sample of patients.
Evidence to show. Using mobility aids: wheelchairs and canes (ASF brochure).
Pass when. Each sampled aid is fitted and sized to the patient.
3. Equipment is checked and faulty items removed
Method. Check the check records for the last 6 months.
Evidence to show. Falls environment checklist (ASF-TOOL-FP-02).
Pass when. Checks are recorded on schedule, and faulty items are marked out of use.
Good practice. Mobility equipment available, fitted to each patient, checked on schedule, and faulty items removed.
Immediate fail (any one means the criterion is not met). Patients who need a walking aid have none available.
Partial because. Equipment is available but checks are not recorded, or faulty items stay in use.
Staff, training and documents
Documents
- Using mobility aids: wheelchairs and canes (ASF brochure)
- Falls environment checklist ward, bathroom, corridor (ASF-TOOL-FP-02)
E-learning
- Slip, Trip & Fall Prevention (Must for nursing and therapy staff)
9.8Routes Are Clear of Clutter and Trip HazardsHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Corridors, exits and patient routes are kept clear of equipment, trolleys, cables and wet floors. Trip hazards are removed promptly, and the route walks are recorded.
Why it matters. Clutter and trip hazards cause a large share of falls in hospitals. A clear route also keeps exits open in an emergency.
Questions the surveyor asks
- Are the patient routes and exits kept clear? Trolleys and equipment should not block a corridor or exit.
- Are wet floors and loose cables removed promptly? A hazard left in place is a fall waiting to happen.
- Are route walks done and recorded? A regular walk shows the condition of the route.
How the surveyor verifies this criterion
Sample. Route walks for the last 3 months, the cleanliness audit record, and a sample of corridors and exits.
1. Routes are clear
Method. Walk the main routes and exits and note any obstruction.
Evidence to show. Cleanliness audit record (ENV-FRM-002).
Pass when. No route or exit is blocked at the time of the walk.
2. Hazards are removed promptly
Method. Check the record of hazards found and how fast they were removed.
Evidence to show. Cleaning of shared clinical and waiting areas (ENV-SOP-002).
Pass when. Each hazard is removed or marked within the set time.
3. Route walks are recorded
Method. Check the route walk record for the last 3 months.
Evidence to show. Unit security and evacuation plan (FLD-PLN-002).
Pass when. Route walks are recorded at least monthly.
Good practice. Routes and exits kept clear, hazards removed quickly, and route walks recorded.
Immediate fail (any one means the criterion is not met). Exits or patient routes are blocked, and no route walks are recorded.
Partial because. Routes are usually clear, but hazards are not removed promptly or walks are not recorded.
Staff, training and documents
Documents
- ENV-FRM-002 Cleanliness audit record
- ENV-SOP-002 Cleaning of shared clinical and waiting areas
- FLD-PLN-002 Unit security and evacuation plan
- EMG-SOP-001 Fire safety and evacuation
E-learning
- Slip, Trip & Fall Prevention (Must for all staff)
- Safety & Emergency Preparedness (Must for all staff)
Who is responsible for Standard 9
Each criterion names the positions responsible for it. Every position links to its own terms of reference.
| Criterion | Responsible | Supports |
|---|---|---|
| 9.1 Handrails Are Fitted Where Patients Walk | Maintenance supervisor | Housekeeping supervisor Registered nurse |
| 9.2 Toilets and Washrooms Have Correct Grab Bars | Maintenance supervisor | Cleaner (hospital) Housekeeping supervisor |
| 9.3 An Accessible Toilet Is Available Where Patients Need One | Maintenance supervisor | Chief operating officer (COO) Registered nurse |
| 9.4 Toilet and Washroom Doors Allow Rescue | Fire safety officer | Security guard Maintenance supervisor |
| 9.5 Lighting Supports Safe Movement | Maintenance supervisor | Housekeeping supervisor |
| 9.6 Beds and Chairs Are Set to Reduce Fall Risk | Registered nurse | Biomedical equipment technician Patient transporter / porter |
| 9.7 Walking Aids and Mobility Equipment Are Available and Checked | Biomedical equipment technician | Registered nurse |
| 9.8 Routes Are Clear of Clutter and Trip Hazards | Housekeeping supervisor | Cleaner (hospital) Patient transporter / porter |
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 |
|---|---|---|---|
| Chief operating officer (COO) | Hospital director | Maintenance supervisor; housekeeping supervisor; fire safety officer | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
| Maintenance supervisor | Chief operating officer (COO) | Lift / elevator technician; biomedical equipment technician | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
| Lift / elevator technician | Maintenance supervisor | None | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
| Biomedical equipment technician | Maintenance supervisor | None | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
| Housekeeping supervisor | Chief operating officer (COO) | Cleaner (hospital) | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
| Cleaner (hospital) | Housekeeping supervisor | None | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
| Fire safety officer | Chief operating officer (COO) | Security guard | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
| Security guard | Fire safety officer | None | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
| Patient transporter / porter | Head of nursing (per ward) | None | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
| Registered nurse | Head of nursing (per ward) | Patient transporter / porter | Facility induction; Slip, Trip & Fall Prevention (general recommendation) |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 9 apply to?
Every facility that admits or treats patients, including outpatient, day-care and home-based services. Scale the criteria to the buildings and services the facility runs.
What do the colours mean for this standard?
Red (Must) is required in every setting. Green (Medium) is required, adapted to what a humanitarian or transition setting can realistically do. Yellow (Minimum) is the lowest acceptable level in a humanitarian setting. In standard settings, every criterion is Must.
Must handrails be fitted along patient routes?
Where patients walk unaided, yes. Under 9.1 handrails are fitted on corridors and stairs used by patients, and checked for firm fixing.
Must an accessible toilet be available?
Where patients need one, yes. Under 9.3 the facility has at least one toilet a wheelchair user can reach and use, with the door, grab bars and space set out for that use.
Must a toilet door open outwards or allow rescue?
Under 9.4 a door can be opened from outside in an emergency. A lock that cannot be opened by staff does not meet the criterion.
Must the environment be checked for trip hazards?
Yes. Under 9.8 the routes are walked and checked, and cleared of clutter, wet floors and loose items, and the checks are recorded.
Do I have to use the documents on this page?
No. The policies, SOPs, forms and checklists are drafts to help you. Adapt them to your buildings, write your own, or upload your own. What the assessor checks is that the criterion is met and that you can show how.
What does In process of development mean?
That part of the standard is still being prepared. It may be a document, a course, a reference or a role table. It will be added in a later version.
Guidelines for this standard
10 guidelines 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.
- Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course (World Health Organization)
- WHO global report on falls prevention in older age (2007) (World Health Organization)
- Falls: assessment and prevention in older people and in people 50 and over at higher risk (National Institute for Health and Care Excellence (UK))
- Hospital Safety Index: Guide for Evaluators, 2nd ed. (World Health Organization and Pan American Health Organization)
- EVAC-H: Evacuation of hospitals and their critical areas (Publisher listed on the guideline page)
- Resilient Hospitals: An inter-regional guidance on strengthening resilience to health emergencies and disasters in health facilities (World Health Organization)
- Hospital Emergency Response Checklist (World Health Organization)
- WHO Wheelchair Provision Guidelines (2023) (World Health Organization)
- Priority assistive products list (2016) (World Health Organization)
- Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care (World Health Organization)
Also relevant to this standard:
- Building construction – Accessibility and usability of the built environment (ISO 21542:2021) (International Organization for Standardization)
- Health Building Note 15-01: Accident & emergency departments – Planning and design guidance (Department of Health and Social Care / NHS England (UK))
References
- World Health Organization (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Geneva: WHO.
- World Health Organization (2007). WHO Global Report on Falls Prevention in Older Age. Geneva: WHO.
- National Institute for Health and Care Excellence. Falls: assessment and prevention in older people and in people 50 and over at higher risk. London: NICE.
- World Health Organization. Hospital Safety Index: Guide for Evaluators, 2nd edition. Geneva: WHO.
- World Health Organization. Resilient Hospitals: an inter-regional guidance on strengthening resilience to health emergencies and disasters in health facilities. Geneva: WHO.
- World Health Organization. WHO Wheelchair Provision Guidelines (2023). Geneva: WHO.
- International Organization for Standardization. ISO 21542:2021 Building construction – Accessibility and usability of the built environment. Geneva: ISO.