Reception & Information

MANDATORY

5 criteria

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [5] World Health Organization. Framework on integrated, people-centred health services. Geneva: WHO; 2016.

A rights charter that exists only in an office drawer protects nobody. Rights only function as rights if the person they protect knows they have them, in language they actually understand.

1 The charter is displayed but only in the majority language.

A meaningful minority of patients may be functionally unable to read it.

2 The charter is posted but written in legal or clinical language.

Technically available and practically accessible are different things.

3 Staff know the charter exists but have never actively explained it to a patient.

Passive display rarely closes the awareness gap on its own.

Week 1 Check current display location and language coverage.

Week 2 Rewrite in plain language if the current version is legal or clinical in tone.

Week 3 Translate into the languages your patients actually speak.

Ongoing Brief reception staff to actively reference the charter.

Ask a patient directly, don't rely on staff description.

Staff describing the policy and a patient's actual awareness are different things.

Check language coverage against the actual patient population.

A single-language charter can look complete while failing a meaningful share of patients.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.

REFERENCES

1. [6] World Health Organization. Tracking universal health coverage: financial protection global monitoring report. Geneva: WHO; 2021.

A patient who doesn't know the cost of care until the bill arrives cannot make an informed choice about their own treatment, and for an ambulatory visit that's often paid out of pocket at the point of care, this matters immediately, not eventually.

1 Pricing is disclosed for the main procedure but not consistently for add-ons.

Ancillary charges often accumulate without the same disclosure discipline.

2 A written estimate exists but in language patients find hard to use.

Technically available and practically useful are different things.

3 Disclosure happens reliably for scheduled visits but less for same-day walk-ins.

Time pressure in urgent same-day visits can compress the disclosure step.

Week 1 Review recent bills against whether pricing was disclosed beforehand.

Week 2 Build a simple written pricing estimate template.

Week 3 Brief reception staff to provide it consistently, including for walk-ins.

Ongoing Spot-check patient recall of pricing periodically.

Ask a patient what they were told, not what the policy says.

The gap between policy and lived experience is exactly what this checks.

Check same-day walk-in visits specifically.

Disclosure discipline most commonly erodes under time pressure.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [7] United Nations. Convention on the Rights of Persons with Disabilities. New York: UN; 2006. Article 9.

A standard-height desk forces a wheelchair user to look up at whoever is helping them — an undignified position that's specific, well-observed, and easily fixed once someone actually checks for it.

1 A lower section was built but has become a storage spot for overflow items.

Good design intentions don't guarantee the space stays usable in daily practice.

2 The accessible point exists but is positioned away from the main queue.

Physical accessibility without dignified positioning only partly closes the gap.

3 New staff aren't briefed on the accessible point during induction.

Awareness fades from practice if never actively reinforced.

Week 1 Check current desk height against accessible guidelines.

Week 2 Identify the lowest-cost way to add an accessible section if none exists.

Week 3 Clear and designate the section, briefing all staff.

Ongoing Include the accessible point in routine walk-throughs.

Physically check the height yourself.

A technically accessible but cluttered section doesn't function as intended.

Ask a staff member to demonstrate, not just describe.

Genuine use versus theoretical awareness shows in how confidently they point to it.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.

REFERENCES

1. [8] Health literacy and plain-language communication are established determinants of patient understanding and engagement in care decisions, consistently identified in patient safety literature as distinct from the simple provision of information.

Providing information and a patient genuinely understanding it are two different things, and the gap between them is where informed decisions quietly fail to happen.

1 Plain language is used for major decisions but reverts to shorthand for routine information.

Simplification effort concentrates on high-stakes moments.

2 Verification happens for complex decisions but not everyday instructions.

Misunderstood routine instructions still carry real risk.

3 Materials exist in the majority language but not smaller populations served.

Coverage matching the majority can leave a meaningful minority unsupported.

Week 1 Review current materials and conversation practice for plain-language use.

Week 2 Train staff on teach-back or equivalent techniques.

Week 3 Assess language coverage against actual patient population.

Ongoing Spot-check patient understanding periodically.

Ask a patient to explain back what they were told.

Tests actual comprehension rather than self-reported confidence.

Check materials for a less common language in the patient population.

Coverage gaps concentrate exactly where they're least visible.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.

REFERENCES

1. [9] Structured queue management and wait-time transparency are established elements of patient experience and flow-safety frameworks in ambulatory healthcare settings internationally.

An unmanaged queue creates genuine uncertainty and anxiety, particularly for unwell patients, and makes it harder for staff to notice if someone's condition is quietly worsening while waiting.

1 The queue system works during normal hours but breaks down when busy.

The system is most needed exactly when under the most strain.

2 Wait-time information is displayed but not updated as conditions change.

Stale information can be worse than none.

3 Monitoring happens informally for obviously unwell patients, not systematically for everyone.

Deterioration can be subtle and easy to miss without a systematic check.

Week 1 Observe current queue practice during a known busy period.

Week 2 Establish a defined system with visible wait-time communication.

Week 3 Build a periodic waiting-area check into staff routine.

Ongoing Review wait-time accuracy periodically.

Observe during a genuinely busy period.

Systems that work fine when quiet often reveal gaps under pressure.

Ask how long since the waiting area was last checked for condition changes.

A specific answer reveals genuine practice versus a theoretical process.