Care & Treatment

MANDATORY

12 criteria

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

REFERENCES

1. [16] World Health Organization. WHO guidelines for safe surgery 2009: safe surgery saves lives. Geneva: WHO; 2009.

A signature on a consent form proves a document was signed, not that the patient understood what they agreed to. Genuine consent requires genuine understanding, verified, not assumed from a signature.

1 Conversation happens for major procedures but is rushed for routine ones.

Routine-seeming procedures still deserve genuine understanding.

2 Understanding is assumed from the patient nodding along.

A nod doesn't confirm genuine comprehension.

3 Alternatives are mentioned but not genuinely explored.

A passing mention isn't the same as a real discussion.

Week 1 Observe current consent practice for genuine conversation versus form presentation.

Week 2 Train staff on teach-back verification for consent specifically.

Week 3 Build alternatives discussion into the standard consent process.

Ongoing Spot-check patient understanding after consent conversations.

Ask the patient, not the clinician, to explain the procedure.

This tests actual understanding, not staff confidence in their own explanation.

Check for rushed consent on routine procedures specifically.

This is where genuine practice most commonly erodes.

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

REFERENCES

1. [17] Credential verification failures are a recurring, preventable category in patient safety literature — the checkable fact is whether verification happened directly with the issuing body, not whether a certificate was filed.

A lapsed or fraudulent credential discovered only after harm occurs is a preventable failure — verification with the actual issuing body, not just checking a certificate exists, is what catches this before it matters.

1 Verification happens at hiring but is never repeated.

A credential valid at hiring can lapse years into employment.

2 Verification happens for physicians but less consistently for other clinical staff.

Coverage often concentrates on the most visible role.

3 A response protocol exists but has never actually been used or tested.

An untested protocol may not translate smoothly into real action.

Week 1 Audit current credential verification practice for all clinical staff.

Week 2 Establish direct verification with issuing bodies where not already done.

Week 3 Set a periodic recheck schedule.

Ongoing Review credential currency on the defined schedule.

Ask how verification was done for a specific staff member, by name.

A specific example reveals whether this is genuine practice.

Ask about non-physician clinical staff specifically.

Coverage often concentrates on physicians, leaving other roles less verified.

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

REFERENCES

1. [18] World Health Organization. WHO guidelines on hand hygiene in health care. Geneva: WHO; 2009.

Hand hygiene compliance is one of the most well-established, evidence-based infection prevention practices, and its value depends entirely on it actually happening at the right moments, not on hand hygiene facilities simply being present.

1 Compliance is strong for obvious contacts but weaker for brief interactions.

Perceived low-risk contacts often receive less consistent attention.

2 Stations exist but are sometimes out of supply.

An empty dispenser provides no real protection.

3 Audits happen but only during announced observation periods.

Behaviour during known observation may not reflect routine practice.

Week 1 Conduct an unannounced observation of current hand hygiene practice.

Week 2 Address any station accessibility or supply gaps found.

Week 3 Establish a periodic, partly unannounced audit schedule.

Ongoing Track compliance trends and address any decline.

Observe unannounced, not during a scheduled audit.

Announced observation can produce artificially high compliance.

Check dispenser supply levels directly.

An empty dispenser is a common, easily missed gap.

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

REFERENCES

1. [19] Individualised, documented care assessment is consistently associated with improved continuity of care across providers in health services literature, distinct from assessment quality alone.

A documented assessment that doesn't reflect what was actually found provides no real basis for the care decisions that follow, and can mislead any future clinician who relies on it.

1 Assessments are specific for complex presentations but generic for routine ones.

Perceived complexity often determines documentation effort.

2 Documentation happens same-day but not at the actual time of assessment.

Even same-day reconstruction can lose accuracy.

3 Assessments are specific but use abbreviations unclear to other staff.

Specificity that isn't genuinely readable to others provides limited real value.

Week 1 Review a sample of recent assessments for genuine specificity.

Week 2 Reinforce contemporaneous documentation practice.

Week 3 Standardise abbreviation use for cross-staff readability.

Ongoing Periodically review assessment quality across different clinicians.

Compare two assessments from the same clinician for different patients.

Genuinely different content reveals real specificity; near-identical text reveals a template.

Ask a different staff member to interpret a sample record.

Tests real readability, not just the original author's understanding.

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

REFERENCES

1. [20] World Health Organization. Medication without harm: WHO global patient safety challenge. Geneva: WHO; 2017.

Prescribing errors are among the most common preventable causes of patient harm, and the second-check function can be performed reliably by any trained, designated person — a pharmacist, a second physician, or a senior nurse — not only a clinical pharmacist role many ambulatory clinics don't have.

1 Second checks happen for the most obviously high-risk medications but not a complete list.

A narrower list than the facility's actual high-risk medications leaves real gaps.

2 The second check exists but isn't genuinely independent — same effective judgement twice.

Independent verification requires a second person forming their own judgement.

3 Legibility is good for handwritten scripts but electronic entries have unclear abbreviations.

Illegibility can take digital forms too, not only handwriting.

Week 1 Review a sample of prescriptions for legibility and second-check evidence.

Week 2 Define the facility's specific high-risk medication list.

Week 3 Name and train a specific person or role for the second-check function.

Ongoing Audit second-check genuineness periodically.

Ask who performs the second check, by name and role.

A facility without a clinical pharmacist can still meet this fully if the function is genuinely owned by someone else.

Check for genuine independence, not sequential confirmation by the same judgement.

A real second check reveals itself in a specific, separate example.

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

REFERENCES

1. [21] Joint Commission International. International patient safety goals. 7th ed. Oak Brook (IL): JCI; 2020.

A misidentified patient at any point of contact can result in the wrong medication, procedure, or specimen being attributed to the wrong person — this has to be a universal habit, not a rule that lives in only one part of the clinic's workflow.

1 The practice is strong where introduced first but hasn't spread clinic-wide.

A safety practice introduced for one purpose sometimes doesn't generalise without deliberate effort.

2 Staff verify identity but use a mix of acceptable and unacceptable identifiers.

Partial adherence can be harder to catch than complete absence.

3 Verification happens at check-in and is assumed to carry through the visit.

A single check doesn't protect against a mix-up during a later step.

Week 1 Audit identification practice across all points of contact.

Week 2 Brief all staff that room or slot numbers are never acceptable alone.

Week 3 Extend consistent identification practice clinic-wide.

Ongoing Spot-check identification practice across different service points.

Observe a full visit sequence, not just one department.

This is where the practice most commonly fails to generalise.

Ask specifically whether room or slot numbers are ever used.

A direct question often reveals what a general policy question won't.

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

REFERENCES

1. [22] Continuity of care across facility transitions is identified in cross-border and ambulatory healthcare literature as a distinct risk point, with informal or undefined referral relationships directly linked to preventable delays in care.

An ambulatory clinic is frequently not the top of the care chain, and a patient needing more than this clinic can offer depends on a referral relationship that actually works, not one that exists only in theory.

1 A relationship exists for the most common referral need but not less frequent ones.

Coverage often concentrates on the most visible need.

2 The relationship worked once, historically, but hasn't been confirmed as still active.

Relationships can lapse without anyone at either end noticing.

3 Staff know the process exists but not the specific steps.

General awareness and operational readiness are different things.

Week 1 Identify the most likely referral needs beyond this clinic's capacity.

Week 2 Establish or confirm a specific, named receiving facility relationship for each.

Week 3 Brief all staff on the specific referral process.

Ongoing Confirm the relationship remains active periodically.

Ask for a real, recent referral example, not a description of the relationship.

A real example reveals whether this genuinely functions.

Ask a staff member to describe the process without prompting.

Immediate, confident recall reveals genuine operational readiness.

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

REFERENCES

1. [23] Unreconciled specialist referrals are identified as a contributing factor in a substantial share of ambulatory diagnostic-error malpractice claims, distinct from the referral decision itself.

A referral that's made but never confirmed leaves open the possibility that the patient never actually received the care they were referred for, and nobody at this clinic would know.

1 Confirmation happens for urgent referrals but not routine ones.

Routine referrals can still represent a genuine, missed diagnosis risk.

2 A non-completion is noticed but no specific action follows.

Noticing without acting provides limited real protection.

3 Tracking exists but isn't regularly reviewed for patterns.

Individual tracking without pattern review misses systemic issues.

Week 1 Review recent referrals for evidence of completion confirmation.

Week 2 Establish a specific confirmation process for all referrals, not only urgent ones.

Week 3 Define a specific action for unconfirmed referrals.

Ongoing Review follow-through tracking data periodically for patterns.

Ask for a real example of a referral that wasn't completed and what happened next.

A real example, or its honest absence, reveals whether this system functions.

Check routine referrals specifically, not just urgent ones.

Routine-seeming referrals are where follow-through most commonly lapses.

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

REFERENCES

1. [24] Callen JL, Westbrook JI, Georgiou A, Li J. Failure to follow-up test results for ambulatory patients: a systematic review. J Gen Intern Med. 2011;27(10):1334-1348 — found 6.8% to 62% of laboratory results and up to 36% of radiology results in ambulatory care settings were never followed up.

Failure to follow up on test results is one of the most well-documented, significant patient safety gaps in ambulatory care specifically, directly linked to missed and delayed cancer diagnoses.

1 Communication happens reliably for results reviewed by the ordering clinician personally, but not for others covering.

Coverage transitions are exactly where results can fall through unnoticed.

2 An abnormal-result pathway exists but relies on someone manually noticing the abnormal flag.

Manual reliance without a systematic prompt can miss results under time pressure.

3 Tracking exists but nobody reviews it to look for gaps.

A tracking system that isn't actively reviewed doesn't function as real protection.

Week 1 Review a sample of recent results for evidence of actual patient communication.

Week 2 Establish a specific, faster pathway for abnormal results.

Week 3 Build a tracking mechanism that surfaces uncommunicated results.

Ongoing Review the tracking system periodically for any gap.

Ask for a real, recent example and trace whether the patient actually received the result.

A real example reveals whether this is genuine practice or assumed.

Ask specifically about coverage situations — a different clinician handling a colleague's results.

This is where the process most commonly breaks down.

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

REFERENCES

1. [25] Established international medical ethics guidance recognizes the offer of a trained chaperone for sensitive examinations as a formal professional standard, irrespective of the gender of the clinician or patient, reflected in professional body guidance across many countries.

A chaperone protects both patient dignity and safety during sensitive examinations, and functions as a genuine safeguard only when trained and consistently offered — a friend or family member accompanying the patient is not a substitute for this role.

1 Chaperones are offered for gynaecological exams but not consistently for other sensitive exams.

Sensitivity extends beyond one specific examination type, per the patient's own perception.

2 A chaperone is present but was never specifically trained for the role.

An untrained bystander doesn't provide the same genuine safeguard.

3 The offer happens but is made so casually that patients don't feel it's a genuine option.

A genuine offer needs to feel like a real choice, not a formality to get through.

Week 1 Review current chaperone offer practice across all relevant examination types.

Week 2 Train designated staff specifically for the chaperone role.

Week 3 Standardise how the offer is made so it feels like a genuine choice.

Ongoing Audit chaperone offer documentation periodically.

Ask a patient directly whether a chaperone was offered, not just whether one was present.

This reveals whether the offer was genuine, not just whether someone happened to be in the room.

Check chaperone training records specifically, not just presence in the room.

An untrained bystander doesn't meet this standard even if physically present.

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

REFERENCES

1. [26] Non-discrimination and equitable treatment are foundational patient rights principles across international healthcare quality frameworks, consistently requiring verification through actual patient experience and observed practice.

A non-discrimination policy that exists only on paper protects nobody. This has to be verified through how patients are actually treated, because discrimination in healthcare rarely announces itself.

1 Policy exists but was never specifically communicated to clinical staff.

A policy that never reaches decision-makers has limited practical effect.

2 Staff describe good intentions but struggle with specific examples.

Genuine practice usually shows in specific examples.

3 A reporting mechanism exists but few patients know it's available.

Availability that isn't communicated functions similarly to unavailability.

Week 1 Review policy scope for coverage of clinical care decisions.

Week 2 Communicate the policy directly to clinical staff with concrete examples.

Week 3 Establish a distinct, communicated discrimination reporting mechanism.

Ongoing Gather patient feedback periodically on equitable treatment.

Ask staff for a specific example, not a general assurance.

Concrete examples distinguish genuine internalisation from stated policy.

Ask how a patient would report a discrimination concern specifically.

A distinct, known pathway is the real evidence.

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

REFERENCES

1. [27] Standard and transmission-based precautions frameworks identify verified reprocessing of reusable equipment as a distinct, essential infection prevention control, separate from general environmental cleanliness.

Reusable equipment is a well-documented pathway for infection transmission between patients when cleaning and sterilisation aren't genuinely verified as complete every single time, not just usually.

1 A process exists for the most obviously invasive equipment but not all reusable items.

Attention concentrates on the most visible risk, missing less obvious equipment.

2 Verification happens but isn't documented, relying on staff memory.

Undocumented verification is hard to distinguish from assumed completion.

3 Staff are uncertain what to do if reprocessing status is unclear for an item.

Uncertainty without a defined response can default to continued use.

Week 1 Inventory all reusable equipment and current reprocessing practice.

Week 2 Establish a defined, documented process for every equipment type.

Week 3 Build a verification step into the standard workflow.

Ongoing Audit reprocessing documentation periodically.

Ask for the verification record for a specific piece of equipment.

A specific, documented example is the real evidence of genuine practice.

Ask what happens when reprocessing status is uncertain.

A confident, specific answer reveals whether this is genuinely handled or left to chance.