Resources · Readiness
Facility Readiness Checklists
Ten department-by-department checklists to walk your facility before a survey — free, no account required, cross-referenced to the ASF Standard chapter each one supports.
How to use this: these are not the ASF Standards themselves — the full criteria, with guidance and worked examples, live on the Standards pages. This is a walk-the-building companion: print a department’s checklist, take it to that department, and see what a supervisor or Coordinator would actually observe. Where a box would stay unchecked, that is a gap to close before self-assessment, not after.
Jump to a Department
1. Front Office & Reception
2. HR & Credentialing
3. Pharmacy & Medication
4. Infection Prevention & Control
5. Patient Records
6. Facilities & Life Safety
7. Emergency Preparedness
8. Governance & Leadership
9. Quality & Safety Committee
10. Discharge & Continuity
2. HR & Credentialing
3. Pharmacy & Medication
4. Infection Prevention & Control
5. Patient Records
6. Facilities & Life Safety
7. Emergency Preparedness
8. Governance & Leadership
9. Quality & Safety Committee
10. Discharge & Continuity
1. Front Office & Reception
Maps to: Access & Arrival / Reception & Information
- Signage at the entrance is legible, in the local language, and directs a first-time visitor without needing to ask staff twice.
- Registration staff can state the facility’s patient rights statement in their own words, not just point to a poster.
- Waiting times are tracked and a target is displayed publicly.
- A process exists for patients who cannot pay at registration — documented, not improvised case by case.
- Interpreter access (in person, phone, or list of staff languages) is available and staff know how to activate it.
- Complaints/feedback box or channel is visible from the reception desk, not hidden.
- Emergency cases are visibly fast-tracked ahead of routine registration — staff can describe how.
- Billing and pricing information is available in writing before a patient commits to a paid service.
2. Human Resources & Credentialing
Maps to: Governance & Management
- Every clinical staff member’s licence/registration has been verified directly with the issuing body, not just collected as a copy.
- A signed job description exists for every role, matched to what the person actually does.
- Mandatory training completion is tracked centrally — not left to individual memory.
- New-starter induction covers fire safety, infection control, and incident reporting before independent duties begin.
- Locum, agency, or visiting staff are checked to the same credentialing standard as permanent staff.
- A personnel file exists for every staff member, complete and accessible to an auditor within minutes.
- Performance/competency review happens at a defined interval, documented, not just when a problem arises.
- A named person is responsible for tracking licence renewal dates before they lapse.
3. Pharmacy & Medication Management
Maps to: Care & Treatment
- High-alert medications (insulin, opioids, anticoagulants, concentrated electrolytes) are stored and labelled distinctly from look-alike/sound-alike drugs.
- A current, dated medication list exists per patient and is reconciled at every transition of care.
- Controlled substances are stored under dual control with a reconciled register, checked on a fixed schedule.
- Expired or damaged stock is quarantined and disposed of through a documented process, not simply discarded.
- Verbal orders are read back and confirmed before administration.
- A process exists for reporting and reviewing medication errors without blaming the person who reports.
- Cold-chain medications have a monitored, logged temperature record — not just a fridge with no log.
- Patients receive written information about new medications at discharge, in a language they understand.
4. Infection Prevention & Control
Maps to: Safety & Emergency Preparedness
- Hand hygiene compliance is observed and measured on a schedule, with results visible to staff.
- Personal protective equipment is available at point of use, not in a locked store down the corridor.
- A written isolation/precautions protocol exists and staff can describe when to use it.
- Reusable equipment reprocessing (sterilisation, high-level disinfection) follows a documented, auditable cycle.
- Sharps and biomedical waste are segregated, colour-coded, and disposed of through a licensed route.
- Outbreak or cluster detection has a defined trigger and a named person who acts on it.
- Staff vaccination status for relevant diseases is tracked, not assumed.
- Environmental cleaning has a written schedule with sign-off, not an informal routine.
5. Patient Records & Documentation
Maps to: Care & Treatment / Governance & Management
- Every patient has a unique identifier used consistently across every department and every record.
- Records are legible, dated, timed, and signed — paper or electronic.
- Critical/abnormal results have a documented notification pathway with a time target.
- Record access is limited to those with a legitimate care role, with an audit trail for electronic systems.
- Retention periods are defined and followed — records are neither destroyed early nor kept indefinitely without reason.
- A backup/continuity plan exists for records in the event of system failure or fire.
- Discharge summaries are completed before the patient leaves, not days later.
- Patients can request and receive a copy of their own record through a defined process.
6. Facilities, Equipment & Life Safety
Maps to: Environment & Shared Spaces
- Fire extinguishers, alarms, and exit signage are inspected on a documented schedule.
- Emergency exits are unobstructed and unlocked from the inside at all times the facility is occupied.
- Medical equipment has a maintenance and calibration schedule with dated records, not a sticker that has expired.
- Backup power (generator or equivalent) is tested on a fixed schedule and covers life-critical areas.
- Water and medical gas supply have documented contingency plans for interruption.
- Structural and equipment safety hazards identified in the last inspection have a tracked closure date.
- Accessibility for patients with disabilities is addressed — ramps, signage, accessible toilets — not assumed adequate.
- A named person owns facilities safety and can produce the inspection records on request.
7. Emergency Preparedness & Mock Drills
Maps to: Safety & Emergency Preparedness
- A written emergency response plan exists covering fire, mass casualty, and utility failure at minimum.
- Mock drills are conducted on a fixed schedule, not only after an incident or before a survey.
- Every mock drill produces a written report: actions taken, roles, gaps found, corrective action, closure date.
- Staff can state the facility’s emergency code or alert system without checking a poster.
- A specific plan exists for infant/patient elopement or abduction risk, where relevant to the facility type.
- Cardiac/medical emergency response (crash cart, resuscitation team activation) is tested, not only stocked.
- External emergency services (ambulance, fire, police) contact details are current and tested at least annually.
- Lessons from the last real emergency or drill have visibly changed a policy or a layout.
8. Governance & Leadership
Maps to: Governance & Management
- Organisational structure and lines of accountability are documented and known to staff, not just to management.
- Leadership reviews quality and safety data on a fixed schedule, with minutes kept.
- A conflict-of-interest declaration exists for anyone in a purchasing or clinical-governance role.
- Policies are version-controlled, dated, and reviewed on a defined cycle — not written once and forgotten.
- A budget exists for quality improvement activity, not just clinical operations.
- Regulatory and licensing status is current, filed, and accessible on request.
- Whistleblowing/concern-raising has a defined channel that does not require going through a direct supervisor.
- The facility can name who is legally and operationally accountable if something goes seriously wrong.
9. Quality & Patient Safety Committee
Maps to: Governance & Management / Aftercare & Follow-up
- A quality/patient safety committee meets on a fixed schedule with a quorum requirement and minutes.
- Incident reports are reviewed for patterns, not just closed one at a time.
- At least one root-cause analysis has been completed and acted on in the last cycle.
- Patient/family feedback (compliments and complaints) is a standing agenda item, not an occasional mention.
- A defined set of quality indicators is tracked over time and shown to staff, not just to management.
- Corrective actions from the last external or internal review have documented closure evidence.
- Frontline staff are represented on or consulted by the committee, not only senior management.
- The committee’s work connects visibly to the facility’s Improvement Plan.
10. Discharge & Continuity of Care
Maps to: Aftercare & Follow-up
- Discharge criteria are documented and checked before a patient leaves, not assumed by habit.
- Patients receive written discharge instructions in a language and format they can use.
- Follow-up appointments or referrals are booked or clearly arranged before discharge, not left to the patient.
- A process exists to reach patients who miss a critical follow-up.
- Medication changes at discharge are explained to the patient and reconciled against their prior list.
- Transfer to another facility includes a written summary that travels with the patient.
- Readmission within a defined window is reviewed to check whether the original discharge was premature.
- Patients know who to contact after discharge if a problem arises — and that number actually works.
Need a report format for the drill itself? See the Mock Drill Report Templates — fillable formats for Fire, Medical Emergency, and Missing Person drills.
Next Step
Once you have walked each department, run the full self-assessment for your facility type to see exactly which ASF criteria each gap maps to, and get a complete gap report.
