Resources › Policies
All policies in one place, grouped by standard. Use the links to read a document, or download the PDF.
Standard 1: Assessment, Care Planning and Safety
| Document | Title | Criteria | |
|---|---|---|---|
| CON-POL-001 | Patient Rights and Responsibilities | 1.7 | Download PDF |
| CON-POL-002 | Non-Discrimination and Equal Access to Care | 1.5 | Download PDF |
| CON-POL-003 | Patient Council Terms of Reference | 2A.10 | Download PDF |
| INC-POL-001 | Incident Reporting and Management | 2A.6 | Download PDF |
| INC-POL-002 | Complaints and Feedback | 2A.6, 2A.10 | Download PDF |
| REC-POL-001 | Records Management and Retention | 2A.6 | Download PDF |
| HH-POL-001 | Hand Hygiene Policy | 1.2 | Download PDF |
| CLN-POL-001 | Staffing levels and skill mix | 1.1 | Download PDF |
| CLN-POL-002 | Restraint and seclusion | 1.4 | Download PDF |
Standard 2: Operating Theatre and Surgical Safety
| Document | Title | Criteria | |
|---|---|---|---|
| SRG-POL-001 | Surgical safety checklist and team pause | 2.1 | Download PDF |
| SRG-POL-002 | Anaesthesia safety and monitoring | 2.2 | Download PDF |
| SRG-POL-003 | Surgical site infection prevention | 2.3 | Download PDF |
Standard 3: Medicines and Pain
| Document | Title | Criteria | |
|---|---|---|---|
| MNP-POL-001 | Look-alike and sound-alike medicines | 3.1 | Download PDF |
| MNP-POL-002 | Opioid stewardship | 3.2 | Download PDF |
| MNP-POL-003 | Pain assessment and management | 3.3 | Download PDF |
Standard 4: Environment and Accessibility
| Document | Title | Criteria | |
|---|---|---|---|
| ACS-POL-001 | Environment and accessibility for safe movement | 4.1, 4.8 | Download PDF |
Standard 5: Blood Bank
| Document | Title | Criteria | |
|---|---|---|---|
| BLD-POL-001 | Blood bank quality system | 5.8 | Download PDF |
| BLD-POL-002 | Issue of blood against a valid request | 5.5 | Download PDF |
Standard 6: Day Clinic and Day Surgery
| Document | Title | Criteria | |
|---|---|---|---|
| DAY-POL-001 | Patient selection for same-day surgery | 6.1 | Download PDF |
| DAY-POL-002 | Escort and written discharge advice | 6.4 | Download PDF |
Standard 7: Emergency Dispatch
| Document | Title | Criteria | |
|---|---|---|---|
| EDP-POL-001 | Call answering and response times | 7.1, 7.3 | Download PDF |
| EDP-POL-002 | Back-up for power, communication and equipment | 7.6 | Download PDF |
Standard 8: Fertility Clinic
| Document | Title | Criteria | |
|---|---|---|---|
| FRT-POL-001 | Information and consent for fertility treatment | 8.1, 8.2 | Download PDF |
Standard 9: Field Hospital
| Document | Title | Criteria | |
|---|---|---|---|
| FLD-POL-001 | Minimum set-up of a field unit before admission | 9.1 | Download PDF |
| FLD-POL-002 | Standards adapted under constraint: what may change and what may not | 9.3, 9.4 | Download PDF |
| FLD-POL-003 | Volunteer and temporary staff: scope and supervision | 9.6 | Download PDF |
Standard 10: Hospice and Palliative Care
| Document | Title | Criteria | |
|---|---|---|---|
| HSP-POL-001 | Symptom assessment and control | 10.1 | Download PDF |
Standard 11: Procedure Units, Endoscopy and Interventional Care
| Document | Title | Criteria | |
|---|---|---|---|
| PRO-POL-001 | Pre-procedure assessment and suitability | 11.1 | Download PDF |
Standard 12: Obstetrics and Gynaecology
| Document | Title | Criteria | |
|---|---|---|---|
| OBS-POL-001 | Antenatal care schedule and risk review | 12.1 | Download PDF |
| OBS-POL-002 | Birth attendance and staffing | 12.2 | Download PDF |
| OBS-POL-003 | Informed choice in place and mode of birth | 12.7 | Download PDF |
| GYN-POL-001 | Gynaecological assessment and urgent referral pathway | 12.11 | Download PDF |
| GYN-POL-002 | Contraception and reproductive choice | 12.12 | Download PDF |
Standard 13: Mobile Clinic and Outreach
| Document | Title | Criteria | |
|---|---|---|---|
| MOB-POL-001 | Site assessment before each deployment | 13.1 | Download PDF |
| MOB-POL-002 | Deployment equipment and medicines list | 13.2 | Download PDF |
Standard 14: Occupational Health
| Document | Title | Criteria | |
|---|---|---|---|
| OHS-POL-001 | Occupational health assessment standards and confidentiality | 14.1 | Download PDF |
| OHS-POL-002 | Reports to the employer | 14.4 | Download PDF |
| OHS-POL-003 | Conflicts of role for assessors | 14.7 | Download PDF |
Standard 15: Optical and Hearing
| Document | Title | Criteria | |
|---|---|---|---|
| OPT-POL-001 | Clinical standards for sight and hearing tests | 15.1 | Download PDF |
| OPT-POL-002 | Fitting and checking products | 15.3 | Download PDF |
| OPT-POL-003 | Urgent eye and ear referral | 15.7 | Download PDF |
Standard 16: Paediatric Care
| Document | Title | Criteria | |
|---|---|---|---|
| PED-POL-001 | Paediatric care: age, size and weight | 16.1 | Download PDF |
| PED-POL-002 | Child safeguarding | 16.3 | Download PDF |
| PED-POL-003 | Child health checks and immunisation | 16.7 | Download PDF |
Standard 17: Pharmacy
| Document | Title | Criteria | |
|---|---|---|---|
| PHA-POL-001 | Pharmacy accountability and cover | 17.3 | Download PDF |
Standard 18: Physiotherapy
| Document | Title | Criteria | |
|---|---|---|---|
| PHY-POL-001 | Physiotherapy assessment before treatment | 18.1 | Download PDF |
| PHY-POL-002 | Assistant scope and supervision | 18.2 | Download PDF |
Standard 19: Specimen Collection Point
| Document | Title | Criteria | |
|---|---|---|---|
| SPC-POL-001 | Collection procedures by specimen type | 19.2 | Download PDF |
Standard 20: Sports Medicine
| Document | Title | Criteria | |
|---|---|---|---|
| SPM-POL-001 | Athlete assessment before treatment or clearance | 20.1 | Download PDF |
| SPM-POL-002 | Return to sport | 20.2 | Download PDF |
Standard 21: Urgent Care
| Document | Title | Criteria | |
|---|---|---|---|
| URG-POL-001 | Triage on arrival | 21.1 | Download PDF |
| URG-POL-002 | Published limits of service | 21.2 | Download PDF |
Standard 22: Academic Medical Centre
| Document | Title | Criteria | |
|---|---|---|---|
| TCH-POL-001 | Trainee scope of independent practice and supervision | 22.1 | Download PDF |
Standard 23: Multi-Site Governance
| Document | Title | Criteria | |
|---|---|---|---|
| NET-POL-001 | Decision rights between central and site leadership | 23.1 | Download PDF |
| NET-POL-002 | Standard clinical policy and local variation | 23.3 | Download PDF |
| NET-POL-003 | Central credentialing and privileging | 23.4 | Download PDF |
Standard 24: Medical Tourism
| Document | Title | Criteria | |
|---|---|---|---|
| MTR-POL-002 | Language access and interpreters | 24.3 | Download PDF |
| MTR-POL-003 | Travel documentation by destination | 24.6 | Download PDF |
| MTR-POL-004 | Facilitator and agent standard | 24.8 | Download PDF |
Standard 25: Health and Migration
| Document | Title | Criteria | |
|---|---|---|---|
| HMG-POL-001 | Migration-informed, trauma-aware care | 25.1 | Download PDF |
| HMG-POL-002 | Patient understanding and health system navigation | 25.2 | Download PDF |
| HMG-POL-003 | Interpreters and cultural mediators | 25.3 | Download PDF |
| HMG-POL-004 | Evidence for refugee and migrant health | 25.6 | Download PDF |
Standard 26: Dialysis and Renal Replacement
| Document | Title | Criteria | |
|---|---|---|---|
| DIA-POL-001 | Dialysis water standard and testing | 26.1 | Download PDF |
| DIA-POL-002 | Dialyser reuse and reprocessing | 26.4 | Download PDF |
| DIA-POL-003 | Dialysis staffing and competence | 26.11 | Download PDF |
Standard 27: Telemedicine
| Document | Title | Criteria | |
|---|---|---|---|
| TEL-POL-001 | Access to care for patients without digital access | 27.1 | Download PDF |
| TEL-POL-002 | Prescribing during remote consultation | 27.15 | Download PDF |
Standard 28: Long-Term Care
| Document | Title | Criteria | |
|---|---|---|---|
| LTC-POL-001 | Functional maintenance and rehabilitation in long-term care | 28.1 | Download PDF |
Standard 29: Home Care
| Document | Title | Criteria | |
|---|---|---|---|
| HC-POL-001 | The client’s home and household routines | 29.1 | Download PDF |
| HC-POL-002 | Individualised assessment of criminal history findings | 29.10 | Download PDF |
| HC-POL-003 | Medication reminders and administration in the home | 29.16 | Download PDF |
| HC-POL-004 | Caregiver safety in private homes | 29.21 | Download PDF |
| HC-POL-005 | Caregiver safety and distress signalling | 29.23 | Download PDF |
Standard 30: Fitness and Wellness
| Document | Title | Criteria | |
|---|---|---|---|
| FW-POL-001 | Fitness data protection and consent | 30.1 | Download PDF |
Standard 31: Dental Care
| Document | Title | Criteria | |
|---|---|---|---|
| DEN-POL-001 | Single-use items and reprocessing limits | 31.4 | Download PDF |
| DEN-POL-002 | Dental radiography justification and dose optimisation | 31.8 | Download PDF |
| DEN-POL-003 | Sedation policy | 31.15 | Download PDF |
| DEN-POL-004 | Fee disclosure and treatment estimate | 31.19 | Download PDF |
Standard 32: Aesthetic and Cosmetic Procedures (non-surgical only)
| Document | Title | Criteria | |
|---|---|---|---|
| AES-POL-001 | Scope of practice and competence | 32.1 | Download PDF |
| AES-POL-002 | Advertising and claims review | 32.5 | Download PDF |
Standard 33: Laboratory
| Document | Title | Criteria | |
|---|---|---|---|
| LBT-POL-001 | Equipment calibration and traceability | 33.1 | Download PDF |
| LBT-POL-002 | External quality assessment participation | 33.5 | Download PDF |
| LBT-POL-003 | Result authorisation and release | 33.12 | Download PDF |
| LBT-POL-004 | Supplier and reagent qualification | 33.15 | Download PDF |
Standard 34: Rehabilitation
| Document | Title | Criteria | |
|---|---|---|---|
| REH-POL-001 | Individualised rehabilitation plan based on functional assessment | 34.1 | Download PDF |
Standard 35: Critical Care
| Document | Title | Criteria | |
|---|---|---|---|
| CRT-POL-001 | Sedation and delirium management protocol | 35.4 | Download PDF |
| CRT-POL-002 | End-of-life decisions and withdrawal of life-sustaining treatment | 35.6 | Download PDF |
Standard 36: Hospital Emergency Department
| Document | Title | Criteria | |
|---|---|---|---|
| ED-POL-001 | Senior clinician responsibility and specialist escalation | 36.3 | Download PDF |
| ED-POL-002 | Resuscitation area readiness | 36.2 | Download PDF |
Standard 37: Neonatal and Paediatric Hospital Care
| Document | Title | Criteria | |
|---|---|---|---|
| NEO-POL-001 | Neonatal level of care | 37.2 | Download PDF |
Standard 38: Substance Use and Addiction Treatment
| Document | Title | Criteria | |
|---|---|---|---|
| SUB-POL-001 | Individual treatment and prescribing | 38.2 | Download PDF |
| SUB-POL-002 | Confidentiality of substance use information | 38.4 | Download PDF |
Standard 39: Humanitarian and Emergency Operations
| Document | Title | Criteria | |
|---|---|---|---|
| HUM-POL-002 | Deployment exit and handover | 39.2 | Download PDF |
| HUM-POL-003 | Protection and do-no-harm | 39.3 | Download PDF |
| HUM-POL-004 | Staff security, rotation and psychosocial support | 39.5 | Download PDF |
Standard 40: Nutrition and Dietetics
| Document | Title | Criteria | |
|---|---|---|---|
| NUT-POL-001 | Nutrition care by qualified staff | 40.1 | Download PDF |
| NUT-POL-002 | Food safety and hygiene | 40.5 | Download PDF |
Standard 41: Complementary and Traditional Medicine
| Document | Title | Criteria | |
|---|---|---|---|
| TRM-POL-001 | Practitioner qualification and registration | 41.1 | Download PDF |
| TRM-POL-002 | Product safety, sourcing and labelling | 41.4 | Download PDF |
Standard 42: Aftercare, Follow-Up and Post-Discharge Safety
| Document | Title | Criteria | |
|---|---|---|---|
| AFT-POL-001 | Post-discharge complaints and feedback | 42.6 | Download PDF |
Standard 43: Organ and Tissue Transplant
| Document | Title | Criteria | |
|---|---|---|---|
| TXP-POL-001 | Donor consent independent of the transplant team | 43.1 | Download PDF |
| TXP-POL-002 | Organ allocation protocol | 43.2 | Download PDF |
| TXP-POL-003 | No financial incentive | 43.3 | Download PDF |
Standard 44: Access, Findability and Wayfinding
| Document | Title | Criteria | |
|---|---|---|---|
| WAY-POL-001 | Public information about the service | 44.1 | Download PDF |
| WAY-POL-002 | Keeping access information current | 44.5 | Download PDF |
Standard 45: Reception, Waiting and Health Information
| Document | Title | Criteria | |
|---|---|---|---|
| WTG-POL-001 | Waiting time measurement and sharing | 45.1 | Download PDF |
| WTG-POL-002 | Patient questions and teach-back | 45.5 | Download PDF |
Standard 46: Hospital Disaster and Emergency Preparedness
| Document | Title | Criteria | |
|---|---|---|---|
| DIS-POL-001 | Hospital disaster plan ownership and incident lead | 46.1 | Download PDF |
Standard 47: Sepsis, Clinical Deterioration and Venous Thromboembolism
| Document | Title | Criteria | |
|---|---|---|---|
| ANT-POL-001 | Anticoagulant monitoring and reversal | 47.4 | Download PDF |
Standard 49: Advance Care Planning, Palliative Needs and Dignity
| Document | Title | Criteria | |
|---|---|---|---|
| ADV-POL-001 | Advance care planning conversations | 49.1 | Download PDF |
| DGN-POL-001 | Dignity and respect in every interaction | 49.4 | Download PDF |
Standard 50: Diagnostic Imaging
| Document | Title | Criteria | |
|---|---|---|---|
| RAD-POL-001 | Radiation justification and dose optimisation | 50.1 | Download PDF |
| ARC-POL-001 | Image and report retention and retrieval | 50.6 | Download PDF |
Standard 51: Oncology and Cancer Care
| Document | Title | Criteria | |
|---|---|---|---|
| ONC-POL-001 | Multidisciplinary tumour board | 51.5 | Download PDF |
Standard 53: Allergology
| Document | Title | Criteria | |
|---|---|---|---|
| ALR-POL-001 | Allergen immunotherapy protocol | 53.4 | Download PDF |
Standard 54: Dermatology and Skin Clinics
| Document | Title | Criteria | |
|---|---|---|---|
| DRM-POL-001 | Laser and light device safety | 54.3 | Download PDF |
Standard 57: Radiotherapy
| Document | Title | Criteria | |
|---|---|---|---|
| RTH-POL-001 | Radiation protection in the treatment room | 57.4 | Download PDF |
Standard 62: Penitentiary Health Services
| Document | Title | Criteria | |
|---|---|---|---|
| PNT-POL-001 | Equivalence of care, confidentiality and independence of clinical decisions in custody | 62.2 | Download PDF |
Standard BASIS: System BASIS
| Document | Title | Criteria | |
|---|---|---|---|
| SAF-POL-001 | Adult safeguarding policy | B1.14 | Download PDF |
| IPC-POL-001 | Infection prevention and control programme | B1.15 | Download PDF |
| CAN-POL-001 | Duty of candour and disclosure policy | B2.14 | Download PDF |
| APR-POL-001 | Accountable person and governance policy | B2.1 | Download PDF |
Standard 2A: Governance and Safety Culture
| Document | Title | Criteria | |
|---|---|---|---|
| GOV-POL-001 | Governing Body Terms of Reference | 2A.1 | Download PDF |
| GOV-POL-002 | Code of Conduct for Staff | 2A.2 | Download PDF |
| GOV-POL-003 | Policy Development, Approval, Review and Application | 2A.3 | Download PDF |
| DIG-POL-001 | Information Security and Access Control Policy | 2A.4 | Download PDF |
| GOV-POL-004 | Clinical Ethics Consultation Policy and Terms of Reference | 2A.9 | Download PDF |
| GOV-POL-005 | Patient and Family Representative Role in Governance | 2A.10 | Download PDF |
Standard 2C: Sustainability
| Document | Title | Criteria | |
|---|---|---|---|
| PRC-POL-001 | Responsible Procurement Policy | 2C.4 | Download PDF |
Standard 2D: Digital Care and AI
| Document | Title | Criteria | |
|---|---|---|---|
| AI-POL-001 | Responsible Use of AI in Care Policy | 2D.4 | Download PDF |
| AI-POL-002 | Accountability for AI-Assisted Care | 2D.7 | Download PDF |
Standard 2E: Workforce
| Document | Title | Criteria | |
|---|---|---|---|
| WRK-POL-001 | Ongoing competency evaluation policy | 2E.1 | Download PDF |
| WRK-POL-002 | Learning, training and competence policy | 2E.2 | Download PDF |
| WRK-POL-003 | Occupational health, safety and wellbeing policy | 2E.3 | Download PDF |
| WRK-POL-004 | Working hours and rest policy | 2E.9 | Download PDF |
| WRK-POL-005 | Speak-up policy | 2E.10 | Download PDF |
Standard S1: Hospital
| Document | Title | Criteria | |
|---|---|---|---|
| HOS-POL-001 | Medicines management policy | Download PDF | |
| HOS-POL-002 | Pharmacy dispensing policy | Download PDF | |
| HOS-POL-003 | Price transparency policy | Download PDF |
Standard S3: Primary care practice
| Document | Title | Criteria | |
|---|---|---|---|
| PHC-POL-001 | Patient registration and named clinician policy | Download PDF | |
| PHC-POL-002 | Managed conditions and first-contact care list | Download PDF |
Standard S6: Patient transfers and referrals
| Document | Title | Criteria | |
|---|---|---|---|
| PTR-POL-001 | Transfer mode decision and right to refuse | Download PDF | |
| PTR-POL-002 | Transfer insurance, cross-border and data sharing rules | Download PDF |