Standards Map

1.1 Staffing Matches Patient Need

Standard operating procedures (SOPs): ID-SOP-001, STF-SOP-001

Forms: ID-FRM-001, STF-FRM-001, CLN-FRM-001

Policies: CLN-POL-001

1.2 Every Patient Gets a Structured Assessment

Standard operating procedures (SOPs): HH-SOP-001, CLN-SOP-001

Forms: HH-FRM-001, CLN-FRM-002

Policies: HH-POL-001

1.3 There is an Actual Care Plan

Standard operating procedures (SOPs): CON-SOP-001, CLN-SOP-002

Forms: CON-FRM-001, CLN-FRM-003

1.4 Restraint and Seclusion Use Is Governed and Minimised

Standard operating procedures (SOPs): PSF-SOP-001

Guidelines: PSF-GDL-001

Forms: PSF-FRM-001, PSF-FRM-002, CLN-FRM-004

Policies: CLN-POL-002

1.5 Nutrition and Therapeutic Diet Needs Are Actively Managed

Standard operating procedures (SOPs): CLN-SOP-003

Forms: CON-FRM-002, CLN-FRM-005

Policies: CON-POL-002

1.6 Pressure Injury Risk Is Assessed and Actively Prevented

Standard operating procedures (SOPs): EMG-SOP-001, CLN-SOP-004

Forms: EMG-FRM-001, EMG-FRM-002, CLN-FRM-006

1.7 VTE Risk Is Assessed Before Every Admission and Procedure

Standard operating procedures (SOPs): CLN-SOP-005

Forms: CLN-FRM-007

Policies: CON-POL-001

2.1 The Surgical Safety Checklist Is Used

Standard operating procedures (SOPs): SRG-SOP-001

Forms: SRG-FRM-001

Policies: SRG-POL-001

2.2 Anaesthesia Is Delivered Safely

Forms: SRG-FRM-002, SRG-FRM-003

Policies: SRG-POL-002

2.3 Surgical Site Infection Is Actively Prevented

Standard operating procedures (SOPs): SRG-SOP-003

Forms: SRG-FRM-004

Policies: SRG-POL-003

3.1 Look-Alike, Sound-Alike Medications Are Specifically Managed

Registers and logs: MNP-REG-001

Policies: MNP-POL-001

3.2 Opioid Prescribing Is Deliberately Stewarded

Standard operating procedures (SOPs): MNP-SOP-001

Forms: MNP-FRM-001

Policies: MNP-POL-002

3.3 Pain Is Formally Assessed and Reassessed, Not Just Asked About Once

Standard operating procedures (SOPs): MNP-SOP-002

Forms: MNP-FRM-002

Policies: MNP-POL-003

4.1 Handrails Are Fitted Where Patients Walk

Standard operating procedures (SOPs): ACS-SOP-001

Forms: ACS-FRM-001

Policies: ACS-POL-001

4.2 Toilets and Washrooms Have Correct Grab Bars

Forms: ACS-FRM-002

4.3 An Accessible Toilet Is Available Where Patients Need One

Forms: ACS-FRM-002

4.4 Toilet and Washroom Doors Allow Rescue

Forms: ACS-FRM-002

4.5 Lighting Supports Safe Movement

Standard operating procedures (SOPs): ACS-SOP-001

Forms: ACS-FRM-001

4.6 Beds and Chairs Are Set to Reduce Fall Risk

Standard operating procedures (SOPs): ACS-SOP-002

Forms: ACS-FRM-003

4.7 Walking Aids and Mobility Equipment Are Available and Checked

Standard operating procedures (SOPs): ACS-SOP-002

Forms: ACS-FRM-003

Registers and logs: ACS-REG-001

4.8 Routes Are Clear of Clutter and Trip Hazards

Standard operating procedures (SOPs): ACS-SOP-001

Forms: ACS-FRM-001

Policies: ACS-POL-001

5.1 Donors Are Selected and Screened

Standard operating procedures (SOPs): BLD-SOP-001

Forms: BLD-FRM-001

5.2 Each Donation Is Tested

Standard operating procedures (SOPs): BLD-SOP-002

Registers and logs: BLD-REG-001

5.3 Each Donation Is Traceable

Standard operating procedures (SOPs): BLD-SOP-003

Registers and logs: BLD-REG-002

5.4 Storage and Transport Keep Products Within Their Conditions

Standard operating procedures (SOPs): BLD-SOP-004

5.5 Issuing Blood Is Checked

Forms: BLD-FRM-002

Policies: BLD-POL-002

5.6 Staff Are Qualified

No documents linked yet

5.7 Adverse Reactions Are Investigated

Standard operating procedures (SOPs): BLD-SOP-005

Forms: BLD-FRM-003

5.8 Quality Management Is in Place

Policies: BLD-POL-001

5.9 Emergency Release Follows a Written Procedure

Standard operating procedures (SOPs): BLD-SOP-006

Forms: BLD-FRM-004

6.1 Patients Are Selected for Same-Day Surgery

Forms: DAY-FRM-001

Policies: DAY-POL-001

6.2 Anaesthesia and Sedation Are Given by Trained Staff

Standard operating procedures (SOPs): DAY-SOP-002

Registers and logs: DAY-REG-001

6.3 Recovery Is Monitored Until Discharge Criteria Are Met

Standard operating procedures (SOPs): DAY-SOP-001

Forms: DAY-FRM-003

6.4 Each Patient Goes Home With an Adult Escort and Advice

Forms: DAY-FRM-002

Policies: DAY-POL-002

6.5 Theatre Safety Checks Are Done

Standard operating procedures (SOPs): DAY-SOP-004

Forms: DAY-FRM-004

6.6 Surgical Site Infections Are Tracked

No documents linked yet

6.7 Unplanned Admissions Are Reviewed

Standard operating procedures (SOPs): DAY-SOP-003

Registers and logs: DAY-REG-002

6.8 Anaesthesia Is Delivered Safely

No documents linked yet

6.9 The Surgical Safety Checklist Is Used

No documents linked yet

6.10 Surgical Site Infection Is Actively Prevented

No documents linked yet

7.1 Calls Are Answered Within a Set Time

Policies: EDP-POL-001

7.2 Calls Are Triaged by Clinical Priority

Standard operating procedures (SOPs): EDP-SOP-001

Forms: EDP-FRM-001

7.3 Resources Are Dispatched Within a Set Time

Standard operating procedures (SOPs): EDP-SOP-002

Registers and logs: EDP-REG-001

Policies: EDP-POL-001

7.4 Staff Are Trained for Call Handling

Registers and logs: EDP-REG-002

7.5 Each Call Is Recorded

Forms: EDP-FRM-001

7.6 System Resilience Is Planned

Registers and logs: EDP-REG-003

Policies: EDP-POL-002

7.7 Calls Are Reviewed

Standard operating procedures (SOPs): EDP-SOP-003

Forms: EDP-FRM-002

7.8 Waiting Calls Are Re-Prioritised and Escalated

Standard operating procedures (SOPs): EDP-SOP-004

Registers and logs: EDP-REG-004

7.9 A Clinical Supervisor Is Available to Call Takers

Standard operating procedures (SOPs): EDP-SOP-005

Forms: EDP-FRM-003

7.10 The end of the provider’s responsibility is written down

No documents linked yet

7.11 Dispatch decision rule and right to refuse

No documents linked yet

8.1 Patients Receive Clear Information on Treatment

Forms: FRT-FRM-001

Policies: FRT-POL-001

8.2 Consent Is Specific to Each Stage

Forms: FRT-FRM-002

Policies: FRT-POL-001

8.3 Gametes and Embryos Are Identified and Traced

Standard operating procedures (SOPs): FRT-SOP-001

Registers and logs: FRT-REG-001

8.4 Storage Is Secure and Monitored

Standard operating procedures (SOPs): FRT-SOP-002

Registers and logs: FRT-REG-002

8.5 Screening and Donor Checks Are Done

Standard operating procedures (SOPs): FRT-SOP-003

Forms: FRT-FRM-003

8.6 Staff Are Qualified

No documents linked yet

8.7 Adverse Events and Outcomes Are Reviewed

Standard operating procedures (SOPs): FRT-SOP-004

Registers and logs: FRT-REG-003

8.8 Psychological Support Is Offered

Standard operating procedures (SOPs): FRT-SOP-005

Forms: FRT-FRM-004

8.9 A Written Plan Responds to a Gamete or Embryo Mix-Up

Standard operating procedures (SOPs): FRT-SOP-006

8.10 Prices Are Disclosed Before Treatment Begins

No documents linked yet

8.11 Organ and Tissue Traceability, End to End

Standard operating procedures (SOPs): FRT-SOP-007

Forms: FRT-FRM-005

9.1 The Unit Is Set Up to a Minimum Safe Standard

Forms: FLD-FRM-001

Policies: FLD-POL-001

9.2 Triage Works Under Pressure

Standard operating procedures (SOPs): FLD-SOP-001

9.3 Surgical Safety Is Maintained Under Constraint

Policies: FLD-POL-002

9.4 Blood and Medicines Are Managed Under Constraint

Policies: FLD-POL-002

9.5 Referral and Evacuation Routes Are Defined

Registers and logs: FLD-REG-001

Plans and templates: FLD-PLN-001

9.6 Staff Are Qualified and Supervised

Forms: FLD-FRM-002

Policies: FLD-POL-003

9.7 Records Are Kept Under Constraint

Forms: FLD-FRM-003

9.8 Infection Control and Outbreak Response Are in Place

Plans and templates: FLD-PLN-004

9.9 Protection of Patients and Staff Is Planned

Plans and templates: FLD-PLN-002

9.10 Mental Health and Psychosocial Support Are Offered

Standard operating procedures (SOPs): FLD-SOP-002

Forms: FLD-FRM-004

9.11 Handover to Permanent Services Is Planned

Plans and templates: FLD-PLN-003

9.12 Donated Medicines and Equipment Are Checked Before Use

Standard operating procedures (SOPs): FLD-SOP-003

Forms: FLD-FRM-005

9.13 Patients Who Report Sexual Violence Receive a Defined Clinical Response

Standard operating procedures (SOPs): FLD-SOP-004

Forms: FLD-FRM-006

9.14 Patients Are Triaged by Urgency

No documents linked yet

9.15 A Mass-Casualty and Utility-Failure Plan Exists and Is Rehearsed

No documents linked yet

9.16 The Surgical Safety Checklist Is Used

No documents linked yet

9.17 Anaesthesia Is Delivered Safely

No documents linked yet

9.18 Surgical Site Infection Is Actively Prevented

No documents linked yet

9.19 Blood Is Verified Before Every Transfusion

No documents linked yet

9.20 The transfer plan is written before departure, with a back-up plan

No documents linked yet

9.21 Dispatch decision rule and right to refuse

No documents linked yet

9.22 Violence Against Staff Is Prevented

No documents linked yet

9.23 Vulnerable Patients Have Specific Protections

No documents linked yet

10.1 Pain and Symptoms Are Assessed and Controlled

Forms: HSP-FRM-001

Policies: HSP-POL-001

10.2 Opioids and Controlled Medicines Are Managed Safely

No documents linked yet

10.3 The Patient’s Goals and Wishes Are Recorded

Forms: HSP-FRM-002

10.4 Family and Carers Are Supported

Standard operating procedures (SOPs): HSP-SOP-001

Forms: HSP-FRM-003

10.5 Spiritual, Cultural and Psychological Needs Are Addressed

Standard operating procedures (SOPs): HSP-SOP-002

Forms: HSP-FRM-004

10.6 Dying Patients Are Cared for With Dignity

Standard operating procedures (SOPs): HSP-SOP-003

Forms: HSP-FRM-005

10.7 Staff Are Trained in Palliative Care

Registers and logs: HSP-REG-001

10.8 Bereavement Follow-Up Is Offered

Standard operating procedures (SOPs): HSP-SOP-005

Forms: HSP-FRM-003

10.9 Service Quality Is Reviewed

Registers and logs: HSP-REG-002

10.10 Out-of-Hours Symptom Advice Is Available

Standard operating procedures (SOPs): HSP-SOP-004

Registers and logs: HSP-REG-003

10.11 Treatment Limits Are Visible at the Point of Care

Forms: HSP-FRM-006

11.1 Each Patient Is Assessed Before the Procedure

Forms: PRO-FRM-001

Policies: PRO-POL-001

11.2 Products and Medicines Are Verified and Stored Correctly

Standard operating procedures (SOPs): PRO-SOP-001

Forms: PRO-FRM-002

Registers and logs: PRO-REG-001

11.3 The Practitioner Is Trained for Each Procedure

Registers and logs: PRO-REG-002

11.4 Consent Covers Risks and Complications

Standard operating procedures (SOPs): PRO-SOP-002

Forms: PRO-FRM-003

11.5 Complications Are Managed Through a Defined Pathway

Standard operating procedures (SOPs): PRO-SOP-003

Forms: PRO-FRM-004

11.6 Emergency Response Is Ready

Standard operating procedures (SOPs): PRO-SOP-004

11.7 Sterile Technique and Infection Control Are Practised

Standard operating procedures (SOPs): PRO-SOP-005

Forms: PRO-FRM-005

11.8 Follow-Up Is Arranged

No documents linked yet

11.9 Product Recalls and Adverse Reactions Are Acted On

Standard operating procedures (SOPs): PRO-SOP-006

Forms: PRO-FRM-004, PRO-FRM-006

Registers and logs: PRO-REG-001

12.1 Antenatal Care Follows a Schedule

Forms: OBS-FRM-001

Policies: OBS-POL-001

12.2 Birth Is Attended by Trained Staff

Forms: OBS-FRM-002

Policies: OBS-POL-002

12.3 Emergency Obstetric Response Is Ready

Standard operating procedures (SOPs): OBS-SOP-001

Forms: OBS-FRM-003

12.4 Blood Is Available for Obstetric Emergencies

Standard operating procedures (SOPs): OBS-SOP-002

12.5 Neonatal Care Is Available

Standard operating procedures (SOPs): OBS-SOP-003

Forms: OBS-FRM-004

12.6 Postnatal Care Is Provided

Standard operating procedures (SOPs): OBS-SOP-004

Forms: OBS-FRM-005

12.7 Women Are Informed and Involved in Choices

Forms: OBS-FRM-006

Policies: OBS-POL-003

12.8 Maternal and Perinatal Outcomes Are Reviewed

Registers and logs: OBS-REG-001

12.9 Mother and Newborn Are Identified Together

Forms: OBS-FRM-002, OBS-FRM-004

12.10 Deterioration After Birth Is Recognised With an Early-Warning Tool

Standard operating procedures (SOPs): OBS-SOP-006

Forms: OBS-FRM-008

12.11 Gynaecological Problems Are Assessed Through a Defined Pathway

Forms: GYN-FRM-001

Policies: GYN-POL-001

12.12 Contraception and Reproductive Choice Are Offered

Forms: GYN-FRM-002

Policies: GYN-POL-002

12.13 Cervical and Breast Screening Is Offered and Followed Up

Standard operating procedures (SOPs): GYN-SOP-001

Registers and logs: GYN-REG-001

12.14 Care After Pregnancy Loss Is Provided With Support

Standard operating procedures (SOPs): GYN-SOP-002

Forms: GYN-FRM-003

12.15 Deteriorating Patients Are Recognised Early

No documents linked yet

13.1 Each Site Is Assessed Before Use

Forms: MOB-FRM-001

Policies: MOB-POL-001

13.2 The Unit Carries the Equipment It Needs

Forms: MOB-FRM-002

Policies: MOB-POL-002

13.3 Emergency Transfer Is Planned

Forms: MOB-FRM-003

Plans and templates: MOB-PLN-001

13.4 Records Are Kept and Brought Back

Registers and logs: MOB-REG-001

13.5 Staff Are Trained for the Setting

No documents linked yet

13.6 Consent and Privacy Are Respected in the Community

Standard operating procedures (SOPs): MOB-SOP-001

13.7 Follow-Up Is Arranged

No documents linked yet

13.8 Coverage Is Reviewed

Standard operating procedures (SOPs): MOB-SOP-003

Registers and logs: MOB-REG-002

13.9 The Vehicle Is Roadworthy and Equipped

Standard operating procedures (SOPs): MOB-SOP-004

13.10 Lone Working Has a Check-In and a Response

Standard operating procedures (SOPs): MOB-SOP-002

Registers and logs: MOB-FRM-004

14.1 Assessments Are Clinically Sound and Confidential

Forms: OHS-FRM-001

Policies: OHS-POL-001

14.2 Staff Are Qualified for the Assessments They Make

Registers and logs: OHS-REG-001

14.3 Health Surveillance Follows a Schedule

Standard operating procedures (SOPs): OHS-SOP-001

Registers and logs: OHS-REG-002

14.4 Concerns Are Reported to the Employer in Line With International Guidance

Forms: OHS-FRM-003

Policies: OHS-POL-002

14.5 Workplace Advice Is Given

Standard operating procedures (SOPs): OHS-SOP-002

Forms: OHS-FRM-004

14.6 Return-to-Work Plans Are Made

Standard operating procedures (SOPs): OHS-SOP-003

Forms: OHS-FRM-005

14.7 Assessors Are Free of Conflicting Roles

Forms: OHS-FRM-006

Policies: OHS-POL-003

14.8 Workers Can See Outcomes and Ask for Review

Standard operating procedures (SOPs): OHS-SOP-004

Forms: OHS-FRM-007

15.1 Eye and Hearing Examinations Are Clinically Sound

Forms: OPT-FRM-001

Policies: OPT-POL-001

15.2 Staff Are Qualified for the Service They Give

Registers and logs: OPT-REG-002

15.3 Products Are Fitted and Checked

Forms: OPT-FRM-002

Policies: OPT-POL-002

15.4 Contact Lens and Hearing Aid Hygiene Is Taught

Standard operating procedures (SOPs): OPT-SOP-001

Forms: OPT-FRM-003

15.5 Aftercare and Follow-Up Are Arranged

Standard operating procedures (SOPs): OPT-SOP-002

Forms: OPT-FRM-004

15.6 Complaints About Products Are Recorded and Acted On

Standard operating procedures (SOPs): OPT-SOP-003

Forms: OPT-FRM-005

15.7 Urgent Eye and Ear Findings Are Referred the Same Day

Forms: OPT-FRM-006

Policies: OPT-POL-003

16.1 Care Is Appropriate to Children’s Age and Size

Standard operating procedures (SOPs): PED-SOP-001

Forms: PED-FRM-001

Policies: PED-POL-001

16.2 Consent Is Obtained From a Parent or Guardian

Forms: PED-FRM-002

16.3 Child Safeguarding Is in Place

Registers and logs: PED-REG-001

Policies: PED-POL-002

16.4 Families Are Involved and Supported

Forms: PED-FRM-003

16.5 The Environment Is Child-Friendly and Safe

Forms: PED-FRM-004

16.6 Staff Are Trained in Paediatric Care

Registers and logs: PED-REG-002

16.7 Immunisation and Child Health Checks Are Provided

Standard operating procedures (SOPs): PED-SOP-002

Registers and logs: PED-REG-003

Policies: PED-POL-003

16.8 Children Are Transferred Safely

No documents linked yet

16.9 Child Health Outcomes Are Reviewed

Registers and logs: PED-REG-004

16.10 Emergency Equipment and Weight-Based Dose References Are Available

Forms: PED-FRM-005

16.11 Weight Is Recorded at Each Contact Before a Dose Is Calculated

Standard operating procedures (SOPs): PED-SOP-001

Forms: PED-FRM-006

16.12 Neonatal and paediatric transfers use specialist arrangements

No documents linked yet

17.1 Each Prescription Is Checked Before Dispensing

No documents linked yet

17.2 Counselling Is Given

Standard operating procedures (SOPs): PHA-SOP-001

Forms: PHA-FRM-001

17.3 A Qualified Pharmacist Is Accountable

Registers and logs: PHA-REG-001

Policies: PHA-POL-001

17.4 Dispensing Errors Are Recorded and Reviewed

Registers and logs: PHA-REG-002

17.5 Controlled Medicines Are Recorded

No documents linked yet

17.6 Medicines Are Stored Securely and Correctly

No documents linked yet

17.7 Medicine Supply Is Managed

Standard operating procedures (SOPs): PHA-SOP-002

Registers and logs: PHA-REG-004

17.8 Medicines Are Recalled When Needed

Forms: PHA-FRM-002

17.9 Medicines Are Bought From Licensed Sources

Registers and logs: PHA-REG-003

17.10 Medicines Are Stored and Given Safely

No documents linked yet

18.1 Each Patient Has a Clinical Assessment Before Treatment

Forms: PHY-FRM-001

Policies: PHY-POL-001

18.2 Treatment Is Delivered by Trained Staff

Registers and logs: PHY-REG-001

Policies: PHY-POL-002

18.3 Treatment Is Based on Current Evidence

Forms: PHY-FRM-002

Registers and logs: PHY-REG-002

18.4 Progress Is Measured Against the Goals

Standard operating procedures (SOPs): PHY-SOP-001

Forms: PHY-FRM-003

18.5 Equipment Is Safe and Checked

Registers and logs: PHY-REG-003

18.6 Patients Are Given Advice to Continue at Home

Forms: PHY-FRM-004

18.7 Outcomes Are Reviewed

Registers and logs: PHY-REG-004

19.1 Each Specimen Is Correctly Identified at Collection

Forms: SPC-FRM-001

19.2 Collection Is Done Correctly

Forms: SPC-FRM-002

Policies: SPC-POL-001

19.3 Sharps and Waste Are Handled Safely

No documents linked yet

19.4 Specimens Are Transported Safely and on Time

Standard operating procedures (SOPs): SPC-SOP-001

Registers and logs: SPC-REG-001

19.5 Refused or Unsuitable Specimens Are Recorded

Standard operating procedures (SOPs): SPC-SOP-002

Registers and logs: SPC-REG-002

19.6 Staff Are Trained

No documents linked yet

19.7 Results Reach the Requester

Standard operating procedures (SOPs): SPC-SOP-003

Registers and logs: SPC-REG-003

19.8 Consent or Refusal for Collection Is Recorded

Forms: SPC-FRM-003

20.1 Each Athlete Has a Clinical Assessment

Forms: SPM-FRM-001

Policies: SPM-POL-001

20.2 Return-to-Sport Decisions Are Staged and Documented

Forms: SPM-FRM-002

Policies: SPM-POL-002

20.3 Pre-Participation Checks Are Done Where Required

Forms: SPM-FRM-003

Registers and logs: SPM-REG-001

20.4 Staff Are Qualified for the Care They Give

Registers and logs: SPM-REG-002

20.5 Emergency Response for Sports Events Is Planned

Forms: SPM-FRM-004

Plans and templates: SPM-PLN-001

20.6 Anti-Doping and Medicines Are Handled Correctly

Forms: SPM-FRM-005

20.7 Training Load and Injury Are Reviewed

Registers and logs: SPM-REG-003

20.8 Suspected Head Injury Removes the Athlete From Play

Forms: SPM-FRM-006

21.1 Patients Are Triaged on Arrival

Forms: URG-FRM-001

Policies: URG-POL-001

21.2 The Service Has Defined Limits

Forms: URG-FRM-002

Policies: URG-POL-002

21.3 Emergency Response Is Ready

Registers and logs: URG-REG-001

21.4 Waiting Times Are Measured and Acted On

Registers and logs: URG-REG-002

21.5 Patients Are Given Follow-Up Advice

Forms: URG-FRM-003

21.6 Attendance Patterns Are Reviewed

Registers and logs: URG-REG-003

21.7 Patients Waiting to Be Seen Are Re-Checked

Standard operating procedures (SOPs): URG-SOP-002

Forms: URG-FRM-004

21.8 Patients Can Find the Clinic and Its Services Before Arriving

Forms: URG-FRM-005

21.9 Emergency Equipment and Drugs Are Ready

No documents linked yet

22.1 Resident and Trainee Supervision With Verified, Graduated Autonomy

Registers and logs: TCH-REG-001

Policies: TCH-POL-001

22.2 Patients Are Informed of Trainee Involvement in Their Care

Forms: TCH-FRM-001

22.3 Research Activity Operates Under Independent Ethics Review Before Enrolment

Registers and logs: TCH-REG-002

22.4 Clinical Care and Research Participation Are Clearly Separated in Consent

Forms: TCH-FRM-002

22.5 Conflicts of Interest Between Research and Clinical Care Are Disclosed and Managed

Forms: TCH-FRM-003

Registers and logs: TCH-REG-003

22.6 Teaching Faculty Maintain Verified, Current Clinical Competency

Registers and logs: TCH-REG-004

23.1 Governance Structure Defines Authority Between Central and Site-Level Leadership

Forms: NET-FRM-001

Policies: NET-POL-001

23.2 Incident Learning Is Shared Across Sites, Not Siloed

Registers and logs: NET-REG-001

23.3 Clinical Policy Is Standardised Across Sites, With Any Local Variation Explicitly Justified

Registers and logs: NET-REG-002

Policies: NET-POL-002

23.4 Credentialing and Privileging Are Centrally Verified and Consistently Recognised

Registers and logs: NET-REG-003

Policies: NET-POL-003

23.5 Central Resource and Staffing Decisions Are Evaluated for Site-Level Patient Safety Impact

Forms: NET-FRM-002

23.6 Site-Level Quality Data Is Reviewed by Central Governance

Registers and logs: NET-REG-004

24.1 Pricing Transparency for International Patients

Forms: MTR-FRM-001

24.2 Remote Records Transfer to Home-Country Physician

Forms: MTR-FRM-002

24.3 Language Access for Foreign Patients

Forms: MTR-FRM-003

Policies: MTR-POL-002

24.4 Travel, Accommodation, and Logistics Coordination

Standard operating procedures (SOPs): MTR-SOP-001

Registers and logs: MTR-REG-001

24.5 Post-Return Complication Tracking

Registers and logs: MTR-REG-002

24.6 Travel Documentation Support for International Patients

Forms: MTR-FRM-004

Policies: MTR-POL-003

24.7 International Patient Complaint and Redress Process

Registers and logs: MTR-REG-003

24.8 Facilitator and Agent Verification

Registers and logs: MTR-REG-004

Policies: MTR-POL-004

24.9 Travel-Associated Infection Risk Protocol

Forms: MTR-FRM-005

24.10 Post-Procedure Travel Timing and Venous Thromboembolism Risk

Forms: MTR-FRM-006

25.1 People-Centred Care Adapted to Migration and Displacement Experience

Forms: HMG-FRM-001

Policies: HMG-POL-001

25.2 Supporting Patient Agency Through Understanding of Care and the Health System

Forms: HMG-FRM-002

Policies: HMG-POL-002

25.3 Language and Communication Aids — Interpreters and Cultural Mediators

Registers and logs: HMG-REG-001

Policies: HMG-POL-003

25.4 Collaborative Practice Across Health and Social Services

Standard operating procedures (SOPs): HMG-SOP-001

25.5 Surge Capacity for Migration-Related Demand

Plans and templates: HMG-PLN-001

25.6 Evidence-Informed Care for Refugee and Migrant Populations

Policies: HMG-POL-004

25.7 Staff Reflective Practice, Bias Awareness, and Self-Care in Migration Contexts

Forms: HMG-FRM-003

25.8 Cross-Border Continuity of Care

Forms: HMG-FRM-004

25.9 Camp-Based and Non-Camp Service Model Fit

Forms: HMG-FRM-005

25.10 Legal Status Diversity Recognition

Registers and logs: HMG-REG-004

26.1 Dialysis Water Is Treated and Tested to a Documented Standard

Policies: DIA-POL-001

26.2 Water Treatment Equipment Is Maintained and Monitored Online

Forms: DIA-FRM-001

26.3 Dialysis Fluid and Concentrates Are Prepared to a Documented Procedure

Standard operating procedures (SOPs): DIA-SOP-001

Forms: DIA-FRM-002

26.4 Dialysers Are Reprocessed Safely, Traced, and Used Only Where Permitted

Registers and logs: DIA-REG-001

Policies: DIA-POL-002

26.5 Each Treatment Is Prescribed, and Its Adequacy Is Monitored

Forms: DIA-FRM-003

26.6 Vascular Access Is Assessed, Protected and Its Infections Tracked

Forms: DIA-FRM-004

Registers and logs: DIA-REG-002

26.7 Dialysis Machines Are Checked Before Each Session

Forms: DIA-FRM-005

26.8 Emergency Response During Dialysis Is Ready

Forms: DIA-FRM-006

Plans and templates: DIA-PLN-001

26.9 Infection Prevention Across the Dialysis Unit

Forms: DIA-FRM-007

26.10 Patients Are Informed About Their Dialysis Choices

Forms: DIA-FRM-008

26.11 Staffing and Competence for Dialysis Are Defined

Policies: DIA-POL-003

26.12 Dialysis Outcomes and Incidents Are Reviewed

Registers and logs: DIA-REG-003

27.1 The Service Never Disadvantages a Patient Who Cannot Access It Digitally

Forms: TEL-FRM-001

Policies: TEL-POL-001

27.2 AI Systems Are Introduced in Line With WHO AI Governance Guidance

No documents linked yet

27.3 AI Systems Are Monitored for Unintended Consequences

No documents linked yet

27.4 Clinicians Are Consulted Before an AI System Is Introduced

No documents linked yet

27.5 Accountability for AI-Assisted Care Is Explicitly Defined

No documents linked yet

27.6 Providers Have Access to Ongoing Education and Peer Connection

No documents linked yet

27.7 Clinician Wellbeing and Isolation Risk Are Monitored

Standard operating procedures (SOPs): TEL-SOP-001

Forms: TEL-FRM-002

27.8 Digital Infrastructure Impact Is Assessed, Not Assumed Negligible

No documents linked yet

27.9 Hosting and Technology Procurement Considers Environmental Impact

No documents linked yet

27.10 The Provider Considers Its Reduction of Patient Travel Impact

Forms: TEL-FRM-003

27.11 Staff Are Engaged in Sustainability Practice

No documents linked yet

27.12 Sustainability Commitments Are Reviewed, Not Static

No documents linked yet

27.13 Patient Identity Is Confirmed at Every Remote Consultation

Standard operating procedures (SOPs): TEL-SOP-002

Forms: TEL-FRM-004

27.14 Informed Consent for Remote Care Is Recorded

Forms: TEL-FRM-005

27.15 Prescribing at a Distance Follows a Safe Process

Policies: TEL-POL-002

27.16 Clinical Records From Remote Consultations Are Complete

Forms: TEL-FRM-006

27.17 Technical Failure During a Consultation Has a Safe Route

Standard operating procedures (SOPs): TEL-SOP-003

Forms: TEL-FRM-007

28.1 Individualised Functional Maintenance Plan Based on Assessment

Forms: LTC-FRM-003

Policies: LTC-POL-001

28.2 Coordination Between Therapy and Daily Nursing Care

Standard operating procedures (SOPs): LTC-SOP-003

28.3 Resident and Family Goal-Setting

Forms: LTC-FRM-004

28.4 Function Tracked With Validated Tools, Decline Flagged Early

Registers and logs: LTC-REG-002

28.5 Equipment and Assistive Device Provision Matches Need

No documents linked yet

28.6 Restraint-Free and Least-Restrictive Mobility Support

No documents linked yet

28.7 Environmental Impact Is Assessed Across a 24-Hour Operation

No documents linked yet

28.8 Clinical and Incontinence Waste Is Segregated and Responsibly Disposed

No documents linked yet

28.9 Procurement Considers Environmental Impact

No documents linked yet

28.10 Energy and Water Use Are Monitored and Reduced Where Possible

No documents linked yet

28.11 Residents, Families, and Staff Are Engaged in Sustainability Practice

No documents linked yet

28.12 The Facility Plans for Climate-Related Risk to Resident Safety

No documents linked yet

28.13 Sustainability Commitments Are Reviewed, Not Static

No documents linked yet

28.14 Digital Systems Are Evaluated Before Adoption

No documents linked yet

28.15 Digital Care Never Disadvantages a Resident or Family Who Cannot Use It

No documents linked yet

28.16 Technical Support Is Available for Digital Systems

No documents linked yet

28.17 AI Systems Are Introduced in Line With WHO AI Governance Guidance

No documents linked yet

28.18 AI Systems Are Monitored for Unintended Consequences

No documents linked yet

28.19 Staff Are Consulted Before an AI System Is Introduced

No documents linked yet

28.20 Accountability for AI-Assisted Care Is Explicitly Defined

No documents linked yet

28.21 Residents and Families Are Informed When Care Involves AI

No documents linked yet

28.22 Every Member of the Workforce Is Credentialed for Their Actual Role

No documents linked yet

28.23 Workforce Health and Safety Is Protected, Including Manual Handling

Standard operating procedures (SOPs): LTC-SOP-004

Forms: LTC-FRM-005

28.24 Staff Are Protected From Resident and Family Aggression

Standard operating procedures (SOPs): LTC-SOP-005

28.25 End-of-Life and Palliative Care Is Planned With the Resident

No documents linked yet

28.26 Advance Care Planning Is Discussed and Recorded

No documents linked yet

28.27 Death of a Resident Is Handled With Dignity and Learning

No documents linked yet

29.1 The Client’s Home Remains Theirs to Control

Policies: HC-POL-001

29.2 A Written Statement of Rights Is Provided and Understood

Forms: HC-FRM-001

29.3 The Client Can Request a Caregiver Replacement

Standard operating procedures (SOPs): HC-SOP-001

Forms: HC-FRM-002

29.4 A Reachable Alternate Contact Exists Beyond the Caregiver Themselves

Forms: HC-FRM-003

29.5 Freedom From Abuse and Neglect Is Actively Verified

Standard operating procedures (SOPs): HC-SOP-002

Forms: HC-FRM-004

29.6 Background Screening Uses Verified Identity, Not Name-Based Matching Alone

Standard operating procedures (SOPs): HC-SOP-003

Forms: HC-FRM-005

29.7 Abuse Registries Are Checked in Every Country the Caregiver Has Worked

No documents linked yet

29.8 Any Care-Worker Exclusion Registry Is Specifically Checked

No documents linked yet

29.9 Screening Is Repeated Periodically

No documents linked yet

29.10 A Disqualifying Finding Triggers Individualised Assessment

Policies: HC-POL-002

29.11 A Structured Home Safety Assessment Occurs Before Care Begins

Standard operating procedures (SOPs): HC-SOP-004

Forms: HC-FRM-006

29.12 Identified Hazards Lead to Tracked Remediation

Registers and logs: HC-REG-001

29.13 A Fall Triggers Reassessment

No documents linked yet

29.14 The Home Environment Is Reassessed Periodically

No documents linked yet

29.15 Emergency Access to the Home Is Confirmed

Forms: HC-FRM-007

29.16 Medication Reminders and Administration Are Distinguished

Policies: HC-POL-003

29.17 A Single, Current Medication List Is Shared Across Everyone Involved

Forms: HC-FRM-008

29.18 A Medication Change or Care Transition Triggers Structured Review

Standard operating procedures (SOPs): HC-SOP-005

29.19 Medications Belonging to Different Household Members Are Distinguished and Secured

Standard operating procedures (SOPs): HC-SOP-006

29.20 A Missed or Uncertain Dose Is Actively Followed Up

No documents linked yet

29.21 A Risk Assessment of the Home Occurs Before the First Visit

Forms: HC-FRM-009

Policies: HC-POL-004

29.22 A Workplace Violence Prevention Programme Exists, Adapted for the Home Setting

No documents linked yet

29.23 The Caregiver Has a Way to Signal Distress Discreetly

Policies: HC-POL-005

29.24 Hostile Animals and Environmental Hazards Are Specifically Assessed

No documents linked yet

29.25 Near-Misses Are Actively Reported and Used to Update Risk Assessments

No documents linked yet

29.26 Supervisory Visits Occur On-Site

Standard operating procedures (SOPs): HC-SOP-008

29.27 Personal Care Supervision Includes Observing the Aide Providing Care

No documents linked yet

29.28 Supervision Documentation Captures Objective, Measurable Observations

Forms: HC-FRM-010

29.29 A Change in Client Needs Triggers Care Plan Review

No documents linked yet

29.30 An Identified Deficiency Leads to Retraining and Re-Evaluation

No documents linked yet

29.31 A Coverage Plan Exists for a Solo Caregiver’s Absence

Standard operating procedures (SOPs): HC-SOP-009

Plans and templates: HC-PLN-001

29.32 Caregiver Continuity Is Actively Tracked and Prioritised for High-Need Clients

Registers and logs: HC-REG-003

29.33 New Caregiver Retention Receives Structured Attention in the First 100 Days

Standard operating procedures (SOPs): HC-SOP-010

Forms: HC-FRM-011

29.34 Caregiver Isolation Is Addressed Through Regular Supervisor Contact

Standard operating procedures (SOPs): HC-SOP-007

29.35 Incident Reporting Accounts for Detection Delay in an Unsupervised Setting

Standard operating procedures (SOPs): HC-SOP-011

29.36 Care Is Adapted to a Client’s Migration and Displacement Experience

No documents linked yet

29.37 Language Support Accounts for Persistent, Daily Interaction

No documents linked yet

29.38 Cultural and Religious Practices in the Client’s Home Are Respected

No documents linked yet

29.39 Caregiver Work Authorisation Is Verified Through Legal, Non-Discriminatory Practice

No documents linked yet

29.40 A Caregiver’s Legal Status Change Is Handled With Support

Standard operating procedures (SOPs): HC-SOP-012

29.41 Immigrant Caregivers’ Retention Advantage Is Recognised and Supported

No documents linked yet

29.42 Legal Status Diversity Recognition for Clients

No documents linked yet

29.43 Care Is Documented and Provided to Clients Regardless of Immigration or Legal Status

No documents linked yet

29.44 Staff Reflective Practice and Bias Awareness Extends to How Immigrant Caregivers Are Treated

No documents linked yet

29.45 Continuity Across a Client’s Relocation Is Actively Supported

Standard operating procedures (SOPs): HC-SOP-013

Forms: HC-FRM-012

30.1 Biometric and Health-Tracking Data Is Protected and Appropriately Used

Forms: FW-FRM-001

Policies: FW-POL-001

30.2 Medical Clearance Required Before Post-Injury Programming

Standard operating procedures (SOPs): FW-SOP-001

Forms: FW-FRM-002

30.3 Qualified Staff Deliver Post-Injury Programming

Registers and logs: FW-REG-001

30.4 Individualised Programme Based on Functional Assessment

Forms: FW-FRM-003

30.5 Pain and Warning Sign Recognition, With a Stop Protocol

Standard operating procedures (SOPs): FW-SOP-002

30.6 Communication With Referring Clinician Where Applicable

Forms: FW-FRM-004

30.7 Pre-Participation Screening Is Completed Before Exercise

Standard operating procedures (SOPs): FW-SOP-003

Forms: FW-FRM-005

30.8 Exercise Is Supervised and Instructed by Qualified Staff

Standard operating procedures (SOPs): FW-SOP-004

30.9 Exercise Equipment Is Safe, Maintained and Correctly Set Up

Forms: FW-FRM-006

30.10 Cardiac and Medical Emergencies Are Planned For

Registers and logs: FW-REG-003

Plans and templates: FW-PLN-001

30.11 Members Are Informed of Risks and Give Consent

Forms: FW-FRM-007

31.1 Reusable Instruments Are Sterilised by a Validated Process

Standard operating procedures (SOPs): DEN-SOP-001

Registers and logs: DEN-REG-001

31.2 Sterilisation Is Monitored and the Monitoring Is Recorded

No documents linked yet

31.3 Instrument Processing Follows One-Way Flow

Forms: DEN-FRM-001

31.4 Single-Use Items Are Never Reused

Policies: DEN-POL-001

31.5 Dental Unit Waterlines Are Managed and Tested

Standard operating procedures (SOPs): DEN-SOP-002

Registers and logs: DEN-REG-002

31.6 Between-Patient Turnover of the Dental Chair Is Documented

Forms: DEN-FRM-002

31.7 Aerosol and Splatter Are Controlled

Standard operating procedures (SOPs): DEN-SOP-003

31.8 Dental Radiography Is Justified and Dose-Optimised

Forms: DEN-FRM-003

Policies: DEN-POL-002

31.9 Radiation Protection Programme Is Documented

Registers and logs: DEN-REG-003

Plans and templates: DEN-PLN-001

31.10 Dental Amalgam Waste Is Handled to Prevent Mercury Release

Standard operating procedures (SOPs): DEN-SOP-004

31.11 Sharps and Dental Clinical Waste Are Segregated

No documents linked yet

31.12 Emergency Equipment Is Available and Checked

Registers and logs: DEN-REG-004

31.13 Staff Are Trained in Dental Medical Emergencies

Standard operating procedures (SOPs): DEN-SOP-005

31.14 Local Anaesthetic Doses Are Calculated and Recorded

Forms: DEN-FRM-004

31.15 Sedation Is Offered Only with Competence and Monitoring

Forms: DEN-FRM-005

Policies: DEN-POL-003

31.16 Minor Oral Surgery Is Assessed, Consented and Followed Up

Standard operating procedures (SOPs): DEN-SOP-006

31.17 Dental Records Use Standard Charting and Are Complete

Forms: DEN-FRM-006

31.18 Consent Is Obtained Before Each Procedure

No documents linked yet

31.19 Fees Are Transparent and Shown Before Treatment

Forms: DEN-FRM-007

Policies: DEN-POL-004

31.20 Implants and Prosthetic Components Are Traceable

Registers and logs: DEN-REG-005

31.21 Dental Laboratory Work Is Specified, Traceable and Disinfected

Standard operating procedures (SOPs): DEN-SOP-007

Forms: DEN-FRM-008

31.22 Clinicians Hold Current Licences and Competence

No documents linked yet

31.23 Children and People with Special Needs Are Cared For Safely

Standard operating procedures (SOPs): DEN-SOP-008

31.24 Referral to Other Specialists Is Documented

Forms: DEN-FRM-009

31.25 Oral Health Education Is Given and Recorded

Forms: DEN-FRM-010

32.1 Practitioners Are Qualified for Each Procedure They Perform

Policies: AES-POL-001

32.2 Consent Reflects Realistic Outcomes and Allows Time to Reconsider

Standard operating procedures (SOPs): AES-SOP-001

Forms: AES-FRM-001

32.3 Pre-Procedure Assessment Identifies Contraindications

Standard operating procedures (SOPs): AES-SOP-002

Forms: AES-FRM-002

32.4 Sedation and Anaesthesia Are Safe

Standard operating procedures (SOPs): AES-SOP-003

Forms: AES-FRM-003

32.5 Advertising and Claims Are Accurate

Registers and logs: AES-REG-002

Policies: AES-POL-002

32.6 Follow-Up and Complications Are Managed

Standard operating procedures (SOPs): AES-SOP-004

Forms: AES-FRM-004

33.1 Calibration Current and Traceable to a Reference

Registers and logs: LBT-REG-001

Policies: LBT-POL-001

33.2 Reagent Lots Verified Before Use

Forms: LBT-FRM-001

33.3 Method Validated Before Clinical Use

Standard operating procedures (SOPs): LBT-SOP-001

Registers and logs: LBT-REG-002

33.4 Internal Quality Control Run Before Results Are Released

Standard operating procedures (SOPs): LBT-SOP-002

Registers and logs: LBT-REG-003

33.5 External Quality Assessment Participation

Registers and logs: LBT-REG-004

Policies: LBT-POL-002

33.6 Test Indications, Limitations and Patient Preparation Given to Users

Standard operating procedures (SOPs): LBT-SOP-010

Forms: LBT-FRM-002

33.7 Specimens Accepted, Logged and Rejected by Defined Criteria

Standard operating procedures (SOPs): LBT-SOP-003

Registers and logs: LBT-REG-005

33.8 Specimen Transport Preserves Integrity

Standard operating procedures (SOPs): LBT-SOP-004

Forms: LBT-FRM-003

33.9 STAT Specimens Prioritised and Turnaround Monitored

Standard operating procedures (SOPs): LBT-SOP-005

Registers and logs: LBT-REG-006

33.10 Chain of Custody for Forensic or Legal Specimens

Standard operating procedures (SOPs): LBT-SOP-006

Forms: LBT-FRM-004

33.11 Critical Values Communicated and Receipt Verified

Standard operating procedures (SOPs): LBT-SOP-007

Registers and logs: LBT-REG-007

33.12 Results Authorised Before Release

Forms: LBT-FRM-005

Policies: LBT-POL-003

33.13 Reports Meet a Defined Minimum and Reach the Correct Recipient

Standard operating procedures (SOPs): LBT-SOP-008

33.14 Result Amendments Traceable to the Original

Standard operating procedures (SOPs): LBT-SOP-009

Registers and logs: LBT-REG-008

33.15 Suppliers and Reagents Qualified

Registers and logs: LBT-REG-009

Policies: LBT-POL-004

34.1 Individualised Rehabilitation Plan Based on Functional Assessment

Forms: REH-FRM-001

Policies: REH-POL-001

34.2 Multidisciplinary Team Coordination

Standard operating procedures (SOPs): REH-SOP-001

Registers and logs: REH-REG-001

34.3 Patient and Family Goal-Setting and Education

Standard operating procedures (SOPs): REH-SOP-002

Forms: REH-FRM-002

34.4 Progress Is Measured With Validated Functional Outcome Tools

No documents linked yet

34.5 Equipment and Assistive Device Provision Matches Need

Standard operating procedures (SOPs): REH-SOP-003

Forms: REH-FRM-003

34.6 Discharge and Community Reintegration Planning

Standard operating procedures (SOPs): REH-SOP-004

Forms: REH-FRM-004

34.7 Each Patient Has a Clinical Assessment Before Treatment

No documents linked yet

34.8 Every Discharged Patient Has an Aftercare Plan

Standard operating procedures (SOPs): REH-SOP-005

Forms: REH-FRM-005

34.9 Patients Are Given Advice to Continue at Home

No documents linked yet

35.1 Continuous Physiological Monitoring Appropriate to Acuity

Standard operating procedures (SOPs): CRT-SOP-001

Forms: CRT-FRM-001

35.2 Nurse-to-Patient Ratio Matches Acuity

Registers and logs: CRT-REG-001

35.3 Rapid Response and Deterioration Recognition System

Standard operating procedures (SOPs): CRT-SOP-002

35.4 Sedation and Delirium Management Protocol

Forms: CRT-FRM-002

Policies: CRT-POL-001

35.5 Family Communication and Presence Policy

Standard operating procedures (SOPs): CRT-SOP-003

Forms: CRT-FRM-003

35.6 End-of-Life and Withdrawal of Care Protocol

Forms: CRT-FRM-004

Policies: CRT-POL-002

35.7 Deteriorating Patients Are Recognised Early

No documents linked yet

35.8 Dying Patients Are Cared for With Dignity

No documents linked yet

36.1 Every Arrival Is Triaged Before Waiting

No documents linked yet

36.2 Resuscitation Area Is Always Ready

Registers and logs: ED-REG-001

Policies: ED-POL-002

36.3 A Senior Clinician Is Responsible at All Times

Forms: ED-FRM-001

Policies: ED-POL-001

36.4 Decisions to Admit, Transfer or Discharge Are Recorded and Handed Over

Forms: ED-FRM-002

36.5 Patients Who Leave Before Assessment Are Recorded and Followed Up

Standard operating procedures (SOPs): ED-SOP-003

Registers and logs: ED-REG-002

37.1 Medicines Are Dosed for the Child’s Weight and Age

No documents linked yet

37.2 Newborn Care Is Matched to a Defined Level of Care

Forms: NEO-FRM-001

Registers and logs: NEO-REG-001

Policies: NEO-POL-001

37.3 Families Are Informed and Present in Care

No documents linked yet

37.4 Children Are Protected From Harm

No documents linked yet

37.5 Newborns Are Transferred Safely to a Higher Level of Care

No documents linked yet

38.1 Substance Use Is Assessed With a Validated Tool

Standard operating procedures (SOPs): SUB-SOP-001

Forms: SUB-FRM-001

38.2 Treatment Is Individual and Prescribed by a Licensed Clinician

Forms: SUB-FRM-002

Policies: SUB-POL-001

38.3 Harm Reduction Is Available

Standard operating procedures (SOPs): SUB-SOP-002

Registers and logs: SUB-REG-001

38.4 Information About Use Is Confidential

Policies: SUB-POL-002

38.5 Discharge Is Planned With Links to Community Support

Standard operating procedures (SOPs): SUB-SOP-003

Forms: SUB-FRM-003

39.1 Needs Are Assessed Before Services Start

Forms: HUM-FRM-001

39.2 Every Deployment Has a Defined Exit or Handover

Registers and logs: HUM-REG-001

Policies: HUM-POL-002

39.3 Protection and Do-No-Harm Apply to Every Activity

Policies: HUM-POL-003

39.4 A Mass-Casualty Plan Is Written and Tested

No documents linked yet

39.5 Staff Security and Wellbeing Are Managed

Registers and logs: HUM-REG-002

Policies: HUM-POL-004

40.1 Nutrition Care Is Provided by a Qualified Dietitian or Trained Clinician

Registers and logs: NUT-REG-001

Policies: NUT-POL-001

40.2 Each Patient Has an Individual Nutrition Plan

Forms: NUT-FRM-001

40.3 Malnutrition Is Identified, Monitored and Treated

Standard operating procedures (SOPs): NUT-SOP-001

40.4 Diets and Texture Are Matched to the Swallowing Assessment

Standard operating procedures (SOPs): NUT-SOP-002

Forms: NUT-FRM-002

40.5 Food Service Is Safe and Hygienic

Registers and logs: NUT-REG-002

Policies: NUT-POL-002

41.1 Practitioners Are Qualified and Registered

Registers and logs: TRM-REG-001

Policies: TRM-POL-001

41.2 Patients Are Told What Is and Is Not Supported by Evidence

Standard operating procedures (SOPs): TRM-SOP-001

Forms: TRM-FRM-001

41.3 Conventional Care Is Not Replaced When It Is Needed

Standard operating procedures (SOPs): TRM-SOP-002

Forms: TRM-FRM-002

41.4 Products Are Safe, Sourced, Labelled and Not Misleading

Registers and logs: TRM-REG-002

Policies: TRM-POL-002

41.5 Adverse Events Are Recorded and Reviewed

Registers and logs: TRM-REG-003

42.1 The Discharge Plan Is Written and Passed On

No documents linked yet

42.2 Follow-Up Is Booked Before the Patient Leaves

Forms: AFT-FRM-001

42.3 High-Risk Patients Are Contacted After Discharge

Standard operating procedures (SOPs): AFT-SOP-001

Registers and logs: AFT-REG-001

42.4 Patients Know When and How to Seek Urgent Help

Standard operating procedures (SOPs): AFT-SOP-002

Forms: AFT-FRM-002

42.5 Readmissions and Aftercare Problems Are Reviewed

Registers and logs: AFT-REG-002

42.6 Patients Can Complain After Leaving, and Complaints Are Answered

Registers and logs: AFT-REG-003

Policies: AFT-POL-001

43.1 Donor Consent Obtained Through a Process Independent of the Transplant Team

Forms: TXP-FRM-001

Policies: TXP-POL-001

43.2 Organ Allocation Follows a Transparent, Documented Protocol

Registers and logs: TXP-REG-001

Policies: TXP-POL-002

43.3 No Financial Incentive to Donor or Family

Registers and logs: TXP-REG-002

Policies: TXP-POL-003

43.4 Recipient Evaluation and Informed Consent Process

Standard operating procedures (SOPs): TXP-SOP-001

Forms: TXP-FRM-002

43.5 Organ and Tissue Traceability, End to End

Forms: TXP-FRM-003

43.6 Post-Transplant Follow-Up and Outcome Tracking

Standard operating procedures (SOPs): TXP-SOP-003

Registers and logs: TXP-REG-004

44.1 Patients Can Find the Service Before They Arrive

Forms: WAY-FRM-001

Policies: WAY-POL-001

44.2 The Emergency Entrance Is Clearly Marked and Open

Standard operating procedures (SOPs): WAY-SOP-001

Registers and logs: WAY-REG-001

44.3 Signs Work for People With Limited Literacy or Sight

Forms: WAY-FRM-002

44.4 The Route to Key Services Is Marked and Tested

Standard operating procedures (SOPs): WAY-SOP-003

Registers and logs: WAY-REG-002

44.5 Access Information Is Kept Current Through Change

Registers and logs: WAY-REG-003

Policies: WAY-POL-002

45.1 Waiting Times Are Measured and Shared

Forms: WTG-FRM-001

Policies: WTG-POL-001

45.2 Patients in Urgent Need Are Not Left Unseen

No documents linked yet

45.3 Waiting Patients Are Kept Informed

Standard operating procedures (SOPs): WTG-SOP-001

Forms: WTG-FRM-002

45.4 Health Information Is in Plain Language

Standard operating procedures (SOPs): WTG-SOP-002

Registers and logs: WTG-REG-001

45.5 Patients Can Ask Questions and Get Answers

Forms: WTG-FRM-003

Policies: WTG-POL-002

46.1 A Hospital Disaster Plan Is Written and Owned

Policies: DIS-POL-001

46.2 Hazards Are Assessed, Including Climate and Utilities

Standard operating procedures (SOPs): DIS-SOP-001

Forms: DIS-FRM-001

46.3 Essential Services Continue When Utilities Fail

Registers and logs: DIS-REG-001

46.4 Staff Are Trained and Drills Are Held

Forms: DIS-FRM-002

46.5 The Plan Is Reviewed After Each Activation

Standard operating procedures (SOPs): DIS-SOP-003

47.1 Deterioration Is Detected With a Recognised Score

Forms: DET-FRM-001

47.2 Sepsis Is Recognised and Treated Within a Defined Time

Registers and logs: SEP-REG-001

47.3 Venous Thromboembolism Risk Is Assessed on Admission

No documents linked yet

47.4 Patients on Anticoagulants Are Monitored and Their Reversal Is Planned

Registers and logs: ANT-REG-001

Policies: ANT-POL-001

47.5 Deterioration and Sepsis Events Are Reviewed

Standard operating procedures (SOPs): DET-SOP-002

48.1 Falls Risk Is Assessed and Acted On

No documents linked yet

48.2 Pressure Injury Is Prevented in Patients at Risk

No documents linked yet

48.3 Pressure Injuries Are Staged, Treated and Recorded

Standard operating procedures (SOPs): PRS-SOP-001

Registers and logs: PRS-REG-001

48.4 Structured Handover Is Used at Every Transfer of Care

Forms: HND-FRM-001

48.5 Falls, Pressure Injury and Handover Events Are Reviewed

Standard operating procedures (SOPs): HOV-SOP-001

49.1 Patients Are Asked About Their Wishes for Future Care

Forms: ADV-FRM-001

Policies: ADV-POL-001

49.2 Advance Directives Are Recognised and Followed Where Permitted

Registers and logs: ADV-REG-001

49.3 Palliative Needs Are Identified and Met

Standard operating procedures (SOPs): PAL-SOP-001

49.4 Dignity Is Protected in Every Interaction

Forms: DGN-FRM-001

Policies: DGN-POL-001

49.5 Staff Are Trained in Dignity and Communication

No documents linked yet

50.1 Radiation Dose Optimisation and Justification

Forms: RAD-FRM-001

Policies: RAD-POL-001

50.2 Equipment Quality Assurance and Calibration

Standard operating procedures (SOPs): IMG-SOP-001

Registers and logs: IMG-REG-002

50.3 Timely, Accurate Reporting With Critical Finding Escalation

Registers and logs: IMG-REG-001

50.4 Contrast Media Safety Protocol

Standard operating procedures (SOPs): CTR-SOP-001

Forms: CTR-FRM-001

50.5 MRI Safety Screening and Zone Control

Standard operating procedures (SOPs): MRI-SOP-001

Forms: MRI-FRM-001

50.6 Image and Report Retention, Accessible for Comparison

Registers and logs: ARC-REG-001

Policies: ARC-POL-001

50.7 Resuscitation Equipment Is Ready Right Now

No documents linked yet

51.1 Cytotoxic Drug Handling Follows a Verified Safe-Handling Standard

Standard operating procedures (SOPs): ONC-SOP-001

Registers and logs: ONC-REG-001

51.2 Chemotherapy Dose Is Verified by Independent Two-Person Check

Standard operating procedures (SOPs): ONC-SOP-002

Forms: ONC-FRM-002

51.3 Neutropenic Fever Triggers an Immediate, Time-Bound Response

Standard operating procedures (SOPs): ONC-SOP-003

Registers and logs: ONC-REG-002

51.4 Extravasation Is Recognised and Managed Immediately

Standard operating procedures (SOPs): ONC-SOP-004

Forms: ONC-FRM-003

51.5 Multidisciplinary Tumour Board Informs Treatment Planning

Registers and logs: ONC-REG-003

Policies: ONC-POL-001

51.6 Palliative Care Integrated Alongside Active Treatment

No documents linked yet

51.7 High-Alert Medicines Have Extra Safeguards

No documents linked yet

51.8 Patients Are Triaged by Urgency

No documents linked yet

51.9 Sepsis Is Recognised and Treated Quickly

No documents linked yet

51.10 Pain and Symptoms Are Assessed and Controlled

No documents linked yet

51.11 The Patient’s Goals and Wishes Are Recorded

No documents linked yet

52.1 Suicide Risk Screening and Continuous Observation for High-Risk Patients

Standard operating procedures (SOPs): PSY-SOP-001

Forms: PSY-FRM-001

Registers and logs: PSY-REG-001

52.2 Environmental Ligature Risk Is Identified and Mitigated

Forms: PSY-FRM-002

Registers and logs: PSY-REG-002

52.3 Restraint and Seclusion Used as Last Resort, With Strict Documentation

No documents linked yet

52.4 Psychiatric Medication Management Follows a Defined Interaction and Monitoring Protocol

Standard operating procedures (SOPs): PSY-SOP-002

Forms: PSY-FRM-003

52.5 Staff Are Trained and Drilled in De-escalation, Not Only Briefed

Registers and logs: PSY-REG-003

52.6 Discharge Safety Planning With Follow-Up Care Arranged

Forms: PSY-FRM-004

53.1 Allergy History Is Taken and Recorded

Standard operating procedures (SOPs): ALR-SOP-001

Forms: ALR-FRM-001

53.2 Anaphylaxis Is Recognised and Treated at Once

Standard operating procedures (SOPs): ALR-SOP-002

Registers and logs: ALR-REG-001

53.3 Allergen Testing Is Quality-Controlled and Interpreted by a Clinician

Standard operating procedures (SOPs): ALR-SOP-003

Forms: ALR-FRM-002

53.4 Allergen Immunotherapy Follows a Written Protocol

Forms: ALR-FRM-003

Policies: ALR-POL-001

53.5 Allergy Results Are Communicated and Acted On

Standard operating procedures (SOPs): ALR-SOP-004

Forms: ALR-FRM-004

54.1 Skin Lesions Are Examined and Suspicious Lesions Referred

Standard operating procedures (SOPs): DRM-SOP-001

Forms: DRM-FRM-001

54.2 Skin Procedures Are Done With Sterile Technique

Standard operating procedures (SOPs): DRM-SOP-002

54.3 Laser and Light Devices Are Operated Safely

Registers and logs: DRM-REG-002

Policies: DRM-POL-001

54.4 Systemic Dermatology Drugs Are Monitored

Standard operating procedures (SOPs): DRM-SOP-003

Forms: DRM-FRM-002

54.5 Patients Leave With Written Aftercare and a Booked Follow-Up

Standard operating procedures (SOPs): DRM-SOP-004

Forms: DRM-FRM-003

55.1 Patients Are Assessed for Suitability and Realistic Expectations

Standard operating procedures (SOPs): PLS-SOP-001

Forms: PLS-FRM-001

55.2 Consent Is Informed, Realistic and Given Without Pressure

Forms: PLS-FRM-002

55.3 Anaesthesia and Sedation Are Given by Credentialed Staff

Registers and logs: PLS-REG-001

55.4 The Surgical Safety Checklist and Infection Bundle Are Used

No documents linked yet

55.5 Recovery, Discharge and Follow-Up Are Planned

Standard operating procedures (SOPs): PLS-SOP-002

Forms: PLS-FRM-003

56.1 Cardiac Risk Is Assessed Before Investigation or Procedure

Standard operating procedures (SOPs): CAR-SOP-001

Forms: CAR-FRM-001

56.2 Cardiac Procedures Follow a Defined Safety Standard

Standard operating procedures (SOPs): CAR-SOP-002

Registers and logs: CAR-REG-001

56.3 Defibrillators and Emergency Equipment Are Checked Daily

Forms: CAR-FRM-002

56.4 Antithrombotic Therapy Is Managed Under a Written Plan

No documents linked yet

56.5 Cardiac Patients Leave With a Follow-Up and Risk Reduction Plan

Standard operating procedures (SOPs): CAR-SOP-003

Forms: CAR-FRM-003

57.1 The Radiotherapy Plan Is Justified and Independently Checked Before the First Treatment

Standard operating procedures (SOPs): RTH-SOP-001

Forms: RTH-FRM-001

57.2 Patient Identity and Treatment Site Are Verified Before Every Fraction

Standard operating procedures (SOPs): RTH-SOP-002

Forms: RTH-FRM-002

57.3 Treatment Equipment Is Checked by a Quality Assurance Programme

Standard operating procedures (SOPs): RTH-SOP-003

Registers and logs: RTH-REG-001

57.4 Staff and Visitors Are Protected by Shielding, Controlled Areas and Dosimetry

Registers and logs: RTH-REG-002

Policies: RTH-POL-001

57.5 Patients Receive Written Information on Side Effects and Follow-Up

Forms: RTH-FRM-003

58.1 Every Inpatient Has an Admission Assessment and a Daily Review

Standard operating procedures (SOPs): WRD-SOP-001

Forms: WRD-FRM-001

58.2 Medicines Are Reconciled and Given Safely on the Ward

Standard operating procedures (SOPs): WRD-SOP-002

Registers and logs: WRD-REG-001

58.3 Deterioration Is Recognised and Escalated Without Delay

No documents linked yet

58.4 Falls, Pressure Injuries and Infections Are Prevented on the Ward

No documents linked yet

58.5 Discharge Is Planned and Handed Over Safely

No documents linked yet

59.1 Specialist Referrals Are Triaged and Tracked to an Appointment

No documents linked yet

59.2 Specialist Consultations Are Assessed, Consented and Within the Clinician Scope

Standard operating procedures (SOPs): OMS-SOP-001

Forms: OMS-FRM-001

59.3 Results Are Communicated and Missing Results Are Followed Up

No documents linked yet

59.4 Medicines Are Reviewed at Each Visit and Language Access Is Provided

Forms: OMS-FRM-002

59.5 Follow-Up and Recall Are Planned for Every Patient

Registers and logs: OMS-REG-001

60.1 Surgeons Operate Only Within Their Granted Privileges

Standard operating procedures (SOPs): SSC-SOP-001

Registers and logs: SSC-REG-001

60.2 The Surgical Safety Checklist and Site Marking Are Used for Every Operation

No documents linked yet

60.3 Anaesthesia and Sedation Are Given With Monitoring and Emergency Equipment

No documents linked yet

60.4 Surgical Site Infection and Thrombosis Are Prevented

No documents linked yet

60.5 Patients Recover, Are Discharged and Are Followed Up Safely

No documents linked yet

61.1 Each Patient at Risk of a Fall Has an Individual Prevention Plan in Use

No documents linked yet

61.2 The Environment and Equipment Are Checked for Falls Hazards

No documents linked yet

61.3 Every Fall Is Reported, the Patient Is Checked and the Event Is Reviewed

No documents linked yet

61.4 Staff Are Trained in Falls Prevention

No documents linked yet

61.5 Falls Data Are Reviewed at Set Intervals and Used to Change Practice

No documents linked yet

62.1 Every Person Entering Custody Has a Health Screening and Medical Examination

Standard operating procedures (SOPs): PNT-SOP-001

Forms: PNT-FRM-001

62.2 People in Custody Receive Care of the Same Quality as in the Community

Policies: PNT-POL-001

62.3 Medical Confidentiality Is Protected

No documents linked yet

62.4 Health Staff Do Not Take Part in Restraint or Punishment

Registers and logs: PNT-REG-001

62.5 Mental Health, Self-Harm, Infection and Hospital Transfer Are Managed Under Written Procedures

No documents linked yet

63.1 Every Handover Between Clinicians Uses a Structured Method

Standard operating procedures (SOPs): SHO-SOP-001

63.2 Each Handover Covers the Key Information and the Receiver Confirms It

No documents linked yet

63.3 Deteriorating and High-Risk Patients Are Handed Over With Escalation Status

No documents linked yet

63.4 Patients Moved Between Wards or Facilities Travel With a Written Handover

No documents linked yet

63.5 Handover Is Audited and Failures Are Reviewed

Registers and logs: SHO-REG-001

2A.1 The Board Is Accountable

Standard operating procedures (SOPs): GOV-SOP-001

Forms: GOV-FRM-003

Registers and logs: GOV-REG-001

Policies: GOV-POL-001

2A.2 There Is a Written Strategic Plan

Plans and templates: GOV-PLN-001

Policies: GOV-POL-002

2A.3 Policy Gets Followed

Forms: GOV-FRM-002

Registers and logs: GOV-REG-002

Plans and templates: GOV-PLN-002

Policies: GOV-POL-003

2A.4 Patient Data Is Kept Secure

Standard operating procedures (SOPs): DIG-SOP-001

Forms: DIG-FRM-001

Policies: DIG-POL-001

2A.5 Records Are Kept Exactly as Long as Required

Registers and logs: REC-FRM-003

2A.6 Serious Incidents Get Properly Investigated

Standard operating procedures (SOPs): INC-SOP-001

Forms: INC-FRM-001

Registers and logs: INC-REG-001

2A.7 Safety Culture Is Measured

Standard operating procedures (SOPs): QUA-SOP-001

Forms: QUA-FRM-001

Registers and logs: QUA-REG-001

2A.8 Patient Experience Is Measured Continuously, Not Only After Discharge

Standard operating procedures (SOPs): CON-SOP-002

Forms: CON-FRM-004

Registers and logs: QUA-REG-002

2A.9 An Ethics Consultation Process Exists

Standard operating procedures (SOPs): GOV-SOP-002

Registers and logs: GOV-REG-003

Policies: GOV-POL-004

2A.10 Patients and Families Have a Voice in Governance

Registers and logs: GOV-REG-004

Policies: GOV-POL-005

2B.1 Reception Desk Accessibility

Standard operating procedures (SOPs): ENV-SOP-001

Forms: ENV-FRM-001

2B.2 Waiting and Queue Time Is Actively Managed

Standard operating procedures (SOPs): ACC-SOP-001

Forms: ACC-FRM-001

Registers and logs: ACC-REG-001

2B.3 Water Supply Is Safe and Monitored

Standard operating procedures (SOPs): WAT-SOP-001

Forms: WAT-FRM-001

Plans and templates: WAT-PLN-001

2B.4 Medical Equipment Is Maintained on Schedule

Standard operating procedures (SOPs): EQP-SOP-001

Forms: EQP-FRM-001

Registers and logs: EQP-REG-001

2B.5 Shared Spaces Are Clean

Standard operating procedures (SOPs): ENV-SOP-002

Forms: ENV-FRM-002

2B.6 Facility Risks Are Tracked in One Integrated Register

Standard operating procedures (SOPs): FAC-SOP-001

Registers and logs: FAC-REG-001

2B.7 An Environmental Sustainability Programme Is Active

Forms: ENV-FRM-003

Plans and templates: ENV-PLN-001

2B.8 Facility Signage Is Complete Throughout the Building

Standard operating procedures (SOPs): ENV-SOP-003

Forms: ENV-FRM-005

2B.9 Fault Prevention Is Planned, Not Only Repaired

Standard operating procedures (SOPs): FAC-SOP-002

Registers and logs: FAC-REG-002

Plans and templates: FAC-PLN-001

2B.10 Endoscopy Equipment Is Safe to Use and Properly Reprocessed

Standard operating procedures (SOPs): EQP-SOP-002

Registers and logs: EQP-REG-002

2C.1 Environmental Impact Is Reviewed at Strategic Level

Standard operating procedures (SOPs): ENV-SOP-004

Forms: ENV-FRM-006

2C.2 Staff and Patients Are Informed of Sustainability Goals

Forms: ENV-FRM-007

Registers and logs: ENV-REG-001

Plans and templates: ENV-PLN-002

2C.3 Sustainability Progress Is Reported to Governance

Standard operating procedures (SOPs): ENV-SOP-005

2C.4 Procurement Considers Responsible Stewardship of Resources

Standard operating procedures (SOPs): PRC-SOP-001

Forms: PRC-FRM-001

Policies: PRC-POL-001

2C.5 Energy Use Is Monitored, With a Move Toward Renewable Sources

Standard operating procedures (SOPs): ENV-SOP-006

Forms: ENV-FRM-008

Plans and templates: ENV-PLN-003

2C.6 A Carbon Footprint Baseline Exists

Standard operating procedures (SOPs): ENV-SOP-007

Forms: ENV-FRM-009

2C.7 The Facility Plans for Environmental and Climate Resilience

Standard operating procedures (SOPs): FAC-SOP-003

Forms: FAC-FRM-003

Plans and templates: FAC-PLN-002

2D.1 Digital Care Systems Follow an Assessment and Management Process

Standard operating procedures (SOPs): DIG-SOP-002

Forms: DIG-FRM-002

2D.2 Digital Care Never Disadvantages a Patient Who Cannot Use It

Standard operating procedures (SOPs): DIG-SOP-003

Forms: DIG-FRM-003

2D.3 Technical Expertise Supports Digital Care Systems

Forms: DIG-FRM-004

Plans and templates: DIG-PLN-001

2D.4 AI Systems Are Introduced in Line With WHO AI Governance Guidance

Forms: AI-FRM-001

Policies: AI-POL-001

2D.5 AI Systems Are Monitored for Unintended Consequences

Standard operating procedures (SOPs): AI-SOP-001

Registers and logs: AI-REG-001

2D.6 Staff Are Consulted Before an AI System Is Introduced

Standard operating procedures (SOPs): AI-SOP-002

Forms: AI-FRM-002

2D.7 Accountability for AI-Assisted Care Is Explicitly Defined

Policies: AI-POL-002

2D.8 Patients Are Informed When Their Care Involves AI

Standard operating procedures (SOPs): AI-SOP-003

Forms: AI-FRM-003

2E.1 Ongoing Competency Is Regularly Evaluated

Standard operating procedures (SOPs): WRK-SOP-001

Forms: WRK-FRM-001

Registers and logs: WRK-REG-001

Policies: WRK-POL-001

2E.2 Staff Have Access to Ongoing Education and Skill Development

Registers and logs: WRK-REG-001

Policies: WRK-POL-002

2E.3 Workforce Health and Safety Is Protected

Standard operating procedures (SOPs): WRK-SOP-002, WRK-SOP-003, WRK-SOP-004

Policies: WRK-POL-003

2E.4 Workplace Issues Raised by Staff Are Investigated and Resolved

Standard operating procedures (SOPs): WRK-SOP-005

Forms: WRK-FRM-002

2E.5 Staff Are Protected From Violence and Aggression

Standard operating procedures (SOPs): WRK-SOP-006

Forms: WRK-FRM-003

2E.6 Workforce Feedback Is Gathered and Acted On

Standard operating procedures (SOPs): WRK-SOP-007

Forms: WRK-FRM-004

2E.7 Sick Leave and Attrition Data Inform Organisational Learning

Standard operating procedures (SOPs): WRK-SOP-008

Registers and logs: WRK-REG-002

2E.8 Equality, Diversity and Inclusion Across the Workforce Are Monitored

Standard operating procedures (SOPs): WRK-SOP-009

Registers and logs: WRK-REG-003

2E.9 Working Hours and Rest Are Safe

Registers and logs: WRK-REG-004

Policies: WRK-POL-004

2E.10 Staff Can Raise Concerns Through a Route That Protects Them

Standard operating procedures (SOPs): WRK-SOP-010

Policies: WRK-POL-005

2E.11 Staff Are Trained in Falls Prevention

Registers and logs: WRK-REG-005

S1.1 Patients Are Triaged by Urgency

No documents linked yet

S1.2 Deteriorating Patients Are Recognised Early

No documents linked yet

S1.3 Sepsis Is Recognised and Treated Quickly

No documents linked yet

S1.4 Handoffs Are Structured and Verbal

No documents linked yet

S1.5 Medicines Are Stored Securely and Correctly

No documents linked yet

S1.6 High-Alert Medicines Have Extra Safeguards

No documents linked yet

S1.7 Medicines Are Reconciled at Admission, Transfer and Discharge

No documents linked yet

S1.8 Blood Is Verified Before Every Transfusion

No documents linked yet

S1.9 Critical Laboratory Results Are Acted On

No documents linked yet

S1.10 Every Discharged Patient Has an Aftercare Plan

No documents linked yet

S1.11 Patients at Higher Risk Are Checked On After Discharge

No documents linked yet

S1.12 A Mass-Casualty and Utility-Failure Plan Exists and Is Rehearsed

No documents linked yet

S1.13 Violence Against Staff Is Prevented

No documents linked yet

S1.14 Internal Emergency Alerts Are Clear and Consistent

No documents linked yet

S1.15 Pharmacy Dispenses Safely and Accountably

No documents linked yet

S1.16 Vulnerable Patients Have Specific Protections

No documents linked yet

S1.17 Patient Areas Are Safe From Falls in the Environment

No documents linked yet

S1.18 Healthcare-Associated Infections Are Tracked

No documents linked yet

S1.19 Patients Can Find the Hospital and Its Services Before Arriving

No documents linked yet

S1.20 Prices Are Disclosed Before Treatment Begins

No documents linked yet

S1.21 Resuscitation Equipment Is Ready Right Now

No documents linked yet

S1.22 Medicine Safety Does Not Depend on Software Alone

No documents linked yet

S2.1 Patients Can Find the Clinic and Its Services Before Arriving

No documents linked yet

S2.2 Prices Are Disclosed Before Treatment Begins

No documents linked yet

S2.3 Emergency Equipment and Drugs Are Ready

No documents linked yet

S2.4 Medicines Are Stored and Given Safely

No documents linked yet

S2.5 Healthcare-Associated Infections Are Tracked

No documents linked yet

S3.1 Patients Can Register and Have a Named Clinician

No documents linked yet

S3.2 First-Contact Care Covers Common Conditions

No documents linked yet

S3.3 Continuity of Care Is Maintained

No documents linked yet

S3.4 Referrals to Specialist and Hospital Care Are Timely

No documents linked yet

S3.5 Chronic Conditions Are Managed on a Plan

No documents linked yet

S3.6 The Practice Uses Its Population Data

No documents linked yet

S3.7 Screening Programmes Are Offered and Followed Up

No documents linked yet

S3.8 Patients Can Find the Practice and Its Services Before Arriving

No documents linked yet

S3.9 Prices Are Disclosed Before Treatment Begins

No documents linked yet

S3.10 Emergency Equipment and Drugs Are Ready

No documents linked yet

S3.11 Medicines Are Stored and Given Safely

No documents linked yet

S4.1 Falls, Pressure Injury and Nutrition Are Assessed

No documents linked yet

S4.2 Patients Can Find the Provider and Its Services Before Arriving

No documents linked yet

S4.3 Prices Are Disclosed Before Treatment Begins

No documents linked yet

S4.4 Medicines Are Reconciled at Admission, Transfer and Discharge

No documents linked yet

S4.5 Emergency Equipment and Drugs Are Ready

No documents linked yet

S5.1 Fleet register

No documents linked yet

S5.2 Partner operators are bound by written agreements

No documents linked yet

S5.3 Dispatch records for every transfer

No documents linked yet

S5.4 Receiving hospitals and emergency services agree the handover

No documents linked yet

S5.5 Costs and who pays stated before transfer

No documents linked yet

S6.1 Each segment has a named accountable party

No documents linked yet

S6.2 The end of the provider’s responsibility is written down

No documents linked yet

S6.3 The receiving facility or service accepts the patient before departure

No documents linked yet

S6.4 The transfer plan is written before departure, with a back-up plan

No documents linked yet

S6.5 Pre-transport clinical assessment completed

No documents linked yet

S6.6 Transfer level matches patient need

No documents linked yet

S6.7 Critically ill patients transported with matched staff and equipment

No documents linked yet

S6.8 Neonatal and paediatric transfers use specialist arrangements

No documents linked yet

S6.9 Air transport is planned, authorised and controlled

No documents linked yet

S6.10 Patient consent obtained and documented

No documents linked yet

S6.11 Crew scope of practice matches transfer acuity

No documents linked yet

S6.12 Minimum crew complement written and applied

No documents linked yet

S6.13 Escort doctor qualified and credentialed for the transfer type

No documents linked yet

S6.14 Escort continuity to the handover point

No documents linked yet

S6.15 Certification current before each shift

No documents linked yet

S6.16 Driver training specific to patient transport

No documents linked yet

S6.17 Fatigue management for long-distance transfers

No documents linked yet

S6.18 Vehicle maintenance current and documented

No documents linked yet

S6.19 Medical equipment checked and calibrated

No documents linked yet

S6.20 Medication storage meets requirements

No documents linked yet

S6.21 Vehicle safety equipment present and functional

No documents linked yet

S6.22 Aircraft and cabin equipment suitable for the patient

No documents linked yet

S6.23 Commercial flight: seats, equipment and airline acceptance arranged in advance

No documents linked yet

S6.24 Airport and ground segments are part of the same plan

No documents linked yet

S6.25 Continuous monitoring appropriate to acuity

No documents linked yet

S6.26 Deterioration recognition and response

No documents linked yet

S6.27 Cardiac arrest and life-threatening event protocol

No documents linked yet

S6.28 Diversion to the nearest appropriate facility

No documents linked yet

S6.29 Breakdown or accident contingency

No documents linked yet

S6.30 Mass casualty and surge plan

No documents linked yet

S6.31 Real-time status communication to dispatch

No documents linked yet

S6.32 Structured handover at pickup

No documents linked yet

S6.33 Structured handover at destination and at every segment change

No documents linked yet

S6.34 Written documentation travels with the patient

No documents linked yet

S6.35 Cross-border records and data transfer

No documents linked yet

S6.36 Vehicle cleaned and disinfected between patients

No documents linked yet

S6.37 Personal protective equipment available and used

No documents linked yet

S6.38 Isolation and transmission-risk protocol

No documents linked yet

S6.39 Sharps and biohazard waste disposal

No documents linked yet

S6.40 Crew exposure incident response

No documents linked yet

S6.41 Language-appropriate communication with the patient

No documents linked yet

S6.42 Escort clinicians recognised in the receiving country

No documents linked yet

S6.43 Import of medicines and equipment across borders

No documents linked yet

S6.44 Insurance and liability for the chain

No documents linked yet

S6.45 Post-incident debrief

No documents linked yet

S6.46 Dispatch decision rule and right to refuse

No documents linked yet

B1.1 Patient Identified at Every Point of Contact

ID-SOP-001, ID-FRM-001

B1.2 Hand Hygiene at the Point of Care

HH-POL-001, HH-FRM-001, HH-SOP-001

B1.3 Informed Consent Before Significant Care

CON-SOP-001, CON-FRM-001

B1.4 Falls Are Assessed and Prevented

PSF-SOP-001, PSF-GDL-001, PSF-FRM-001, PSF-FRM-002

B1.5 Non-Discrimination in Access to Care

CON-POL-002, CON-FRM-002

B1.6 Emergency Access and Fire Safety

EMG-SOP-001, EMG-FRM-001, EMG-FRM-002

B1.7 Patients Know Their Rights

CON-POL-001

B1.8 Staff Are Qualified, Verified and Current

STF-SOP-001, STF-FRM-001

B1.9 Medicines Are Prescribed, Stored and Given Safely

PHM-SOP-001, PHM-FRM-001, PHM-FRM-002

B1.10 Sharps and Clinical Waste Are Handled Safely

WST-SOP-001, WST-FRM-001

B1.11 Records Are Complete and Private, and Incidents and Complaints Are Acted On

INC-POL-001, INC-POL-002, REC-POL-001, REC-FRM-001, REC-FRM-002

B1.12 Patients Learn, Decide and Shape the Service

CON-POL-003, INC-POL-002

B1.13 Service Scope Is Declared

GOV-FRM-001

B1.14 Children and Adults Are Protected From Abuse and Neglect

PED-REG-001, PED-POL-002, SAF-POL-001, SAF-REG-001

B1.15 Infection Is Prevented Through a Written Programme

HH-FRM-001, HH-SOP-001, IPC-POL-001, IPC-REG-001

B1.16 Care Is Handed Over Safely Between Clinicians

SHO-REG-001, HND-FRM-001, SHO-SOP-001

B2.1 A Named Person Is Accountable for the Service

APR-POL-001, APR-FRM-001

B2.2 The Service Has a Written Operating Plan and Policies

OPR-PLN-001, OPR-REG-001

B2.3 Policies Are Followed in Practice

PCA-SOP-001, PCA-REG-001

B2.6 Serious Incidents Are Investigated

SIR-SOP-001, SIR-REG-001

B2.7 Patients Are Asked for Feedback at Least Once a Year

PFB-SOP-001, PFB-FRM-001

B2.8 The Board Is Accountable

GOV-POL-001, GOV-SOP-001, GOV-FRM-003, GOV-REG-001

B2.9 There Is a Written Strategic Plan

GOV-PLN-001, GOV-POL-002

B2.10 Safety Culture Is Measured

QUA-SOP-001, QUA-FRM-001, QUA-REG-001

B2.11 Patient Experience Is Measured Continuously, Not Only After Discharge

CON-SOP-002, CON-FRM-004, QUA-REG-002

B2.12 An Ethics Consultation Process Exists

GOV-POL-004, GOV-SOP-002, GOV-REG-003

B2.13 Patients and Families Have a Voice in Governance

GOV-POL-005, GOV-REG-004

B2.14 Patients Are Told Openly When Harm Happens

CAN-POL-001, CAN-REG-001, TRM-SOP-001

B2.15 Digital Care Systems Follow an Assessment and Management Process

DIG-SOP-002, DIG-FRM-002, DIG-PLN-001, DIG-FRM-004

B2.16 Digital Care Never Disadvantages a Patient Who Cannot Use It

DIG-SOP-003, DIG-FRM-003

B2.17 Patients Are Informed When Their Care Involves AI

AI-SOP-003, AI-FRM-003

B2.18 AI Systems Are Governed, Monitored and Introduced With Staff Involvement

AI-POL-001, AI-FRM-001, AI-SOP-001, AI-REG-001, AI-SOP-002, AI-FRM-002, AI-POL-002

B3.1 Reception Desk Accessibility

ENV-SOP-001, ENV-FRM-001

B3.2 Waiting and Queue Time Is Actively Managed

ACC-SOP-001, ACC-FRM-001, ACC-REG-001

B3.3 Water Supply Is Safe and Monitored

WAT-SOP-001, WAT-PLN-001, WAT-FRM-001

B3.4 Medical Equipment Is Maintained on Schedule

EQP-SOP-001, EQP-REG-001, EQP-FRM-001

B3.5 Shared Spaces Are Clean

ENV-SOP-002, ENV-FRM-002

B3.6 Facility Risks Are Tracked in One Integrated Register

FAC-SOP-001, FAC-REG-001

B3.8 Facility Signage Is Complete Throughout the Building

ENV-SOP-003, ENV-FRM-005

B3.9 Fault Prevention Is Planned, Not Only Repaired

FAC-PLN-001, FAC-SOP-002, FAC-REG-002

B3.10 Endoscopy Equipment Is Safe to Use and Properly Reprocessed

EQP-SOP-002, EQP-REG-002

B4.1 Ongoing Competency Is Regularly Evaluated

WRK-POL-001, WRK-SOP-001, WRK-FRM-001

B4.2 Staff Have Access to Ongoing Education and Skill Development

WRK-POL-002, WRK-REG-001

B4.3 Workforce Health and Safety Is Protected

WRK-POL-003, WRK-SOP-002, WRK-SOP-003, WRK-SOP-004

B4.4 Workplace Issues Raised by Staff Are Investigated and Resolved

WRK-SOP-005, WRK-FRM-002

B4.5 Staff Are Protected From Violence and Aggression

WRK-SOP-006, WRK-FRM-003

B4.6 Workforce Feedback Is Gathered and Acted On

WRK-SOP-007, WRK-FRM-004

B4.7 Sick Leave and Attrition Data Inform Organisational Learning

WRK-REG-002, WRK-SOP-008

B4.8 Equality, Diversity and Inclusion Across the Workforce Are Monitored

WRK-SOP-009, WRK-REG-003

B4.9 Working Hours and Rest Are Safe

WRK-POL-004, WRK-REG-004

B4.10 Staff Can Raise Concerns Through a Route That Protects Them

WRK-POL-005, WRK-SOP-010

64.1 An Environmental Sustainability Programme Is Active

ENV-PLN-001, ENV-FRM-003

64.2 Environmental Impact Is Reviewed at Strategic Level

ENV-SOP-004, ENV-FRM-006

64.3 Staff and Patients Are Informed of Sustainability Goals

ENV-PLN-002, ENV-FRM-007, ENV-REG-001

64.4 Sustainability Progress Is Reported to Governance

ENV-SOP-005, ENV-FRM-003

64.5 Procurement Considers Responsible Stewardship of Resources

PRC-POL-001, PRC-SOP-001, PRC-FRM-001

64.6 Energy Use Is Monitored, With a Move Toward Renewable Sources

ENV-SOP-006, ENV-FRM-008, ENV-PLN-003

64.7 A Carbon Footprint Baseline Exists

ENV-SOP-007, ENV-FRM-009

64.8 The Facility Plans for Environmental and Climate Resilience

FAC-SOP-003, FAC-PLN-002, FAC-FRM-003