Governance & Management

MANDATORY

9 criteria

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

REFERENCES

1. [35] Jha AK, Epstein AM. Hospital governance and the quality of care. Health Aff (Millwood). 2010;29(1):182-187.

Without clear leadership accountability, there is no mechanism above day-to-day clinical activity responsible for safety and quality — a small clinic can drift without anyone noticing precisely because no one is specifically responsible for noticing. For a genuine solo practitioner, Adapted does not mean this requirement is waived — it means the practitioner explicitly, formally acknowledges in writing that they hold this responsibility themselves, rather than it remaining an unstated assumption. For a small team of two to five, Adapted means one person is clearly named, even if that person also does clinical work.

1 A named leader exists but spends most time on clinical duties, with little time for oversight.

A title without real time devoted to the function provides limited real oversight.

2 An escalation pathway exists but has never actually been used or tested.

An untested pathway may not translate smoothly into real use.

3 Leadership reviews quality data but rarely acts visibly on findings.

Review without visible action provides limited real improvement.

Week 1 Confirm and document named leadership and defined authority.

Week 2 Establish a specific, communicated escalation pathway for safety concerns.

Week 3 Build genuine time for quality and safety oversight into leadership's role.

Ongoing Track leadership follow-through on identified issues.

For Micro (solo) Write a single, dated statement naming yourself as the accountable person for safety and quality at this practice, and set a recurring time on your own calendar to actually act on it — this alone satisfies the requirement genuinely.

Ask the named leader for a specific, real example of addressing a safety issue.

A real example reveals genuine engagement versus a title alone.

Ask front-line staff how they'd escalate a concern.

Staff-side confirmation reveals whether the pathway genuinely functions.

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

REFERENCES

1. [36] Policy-practice gaps are consistently identified in healthcare quality literature as a distinct failure mode from policy absence.

A policy nobody follows provides the appearance of governance without its function — the real question is whether staff behaviour actually reflects it, which is a fundamentally different, harder thing to verify than confirming a document exists.

1 Policies are followed for established practices but not consistently for newer ones.

Habit reinforces old adherence; new policies need active reinforcement.

2 An adherence check exists but only samples an easily-prepared subset.

A narrow or predictable scope can miss where real gaps live.

3 Gaps are identified but corrective action isn't tracked to completion.

Identification without follow-through leaves the underlying gap unresolved.

Week 1 Select key policies and ask a sample of staff to describe actual application.

Week 2 Establish a genuine adherence-checking mechanism.

Week 3 Build a tracked resolution process for identified gaps.

Ongoing Rotate which policies get checked.

Ask about application, not existence.

These surface very different answers.

Pick a policy area to observe directly, not just review on paper.

Direct observation reveals gaps document review cannot.

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

REFERENCES

1. [37] Patient confidentiality protection frameworks consistently identify physical environment design and staff behaviour, not policy documentation alone, as the practical determinants of actual privacy protection.

A confidentiality policy that exists on paper while screens face waiting areas and conversations happen within earshot provides no real protection.

1 Physical privacy is good in exam rooms but overlooked at the reception counter.

Privacy protection is often strongest where it was deliberately designed.

2 Staff are conscientious when reminded but inconsistent otherwise.

Habitual practice is more reliable than reminded practice.

3 A private space exists but isn't consistently used under time pressure.

Infrastructure for privacy doesn't guarantee its use during a busy day.

Week 1 Audit screen positioning and conversation privacy across all patient-facing areas.

Week 2 Reposition screens and reinforce private space use where gaps are found.

Week 3 Brief staff on habitual, not just reminded, confidentiality practice.

Ongoing Spot-check physical privacy periodically.

Walk the space as a visitor would.

A familiar routine can make an obvious privacy gap invisible to staff.

Ask staff for specific examples of their own privacy practices.

Specific habits reveal genuine internalisation better than reciting policy.

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

REFERENCES

1. [38] Health information security frameworks consistently identify access control and incident response planning, rather than technology sophistication alone, as the primary determinants of practical data protection in resource-constrained settings.

An incomplete or insecure record is a quiet risk — the information a future clinician needs might simply not be there, or might be exposed to someone with no legitimate need to see it.

1 Audits happen but only sample a small, unrepresentative set of records.

A narrow sample can miss where real gaps concentrate.

2 Access controls exist for electronic records but not physical files.

Security attention often concentrates on digital systems.

3 A breach plan exists but has never been reviewed since written.

An unreviewed plan may not reflect current systems or risk.

Week 1 Review the mandatory elements list and recent audit practice.

Week 2 Establish a genuine, regular completeness audit.

Week 3 Review access controls against actual staff roles.

Ongoing Review the breach response plan periodically.

Ask for actual audit records, not a description of intended process.

Dated findings are the only real evidence.

Check physical record access, not only electronic systems.

Security attention often skews toward digital systems while physical files remain loosely controlled.

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

REFERENCES

1. [39] Incident reporting culture, specifically the psychological safety staff feel around reporting without fear of punitive consequence, is consistently identified as the primary determinant of reporting volume, more so than system accessibility alone.

An incident reporting system nobody uses provides no safety value regardless of how well-designed it is — the real barrier to reporting is almost always fear of blame, not the mechanics of the form.

1 Reporting happens for minor incidents but staff hesitate to report their own errors.

Psychological safety often varies by perceived personal exposure.

2 Senior staff report reliably; junior staff report far less.

Hierarchy can create very different real experiences within the same clinic.

3 A non-punitive policy exists but staff recall a past incident where reporting led to consequences.

A single remembered punitive response can undermine trust for a long time afterward.

Week 1 Review reporting volume trends for concerning patterns.

Week 2 Interview a cross-section of staff, including junior staff, about reporting confidence.

Week 3 Address any specific past incident undermining psychological safety.

Ongoing Track reporting volume, investigating any significant drop.

Ask junior staff specifically, not only senior staff.

Hierarchy can create very different real experiences.

Ask about reporting one's own error specifically.

Self-reporting confidence is usually the harder, more revealing test.

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

REFERENCES

1. [40] Scope-of-practice verification, distinct from initial credential checking, is an established governance requirement in healthcare workforce quality frameworks internationally.

A staff member performing tasks beyond their actual licensed scope — even competently, even for years — represents a real, unaddressed risk that only surfaces when something goes wrong, and by then the gap has often existed unnoticed for a long time.

1 Comparison happens for physicians but less consistently for support clinical staff.

Attention often concentrates on the most visible role.

2 A mismatch was identified once but never actually corrected.

Identification without correction leaves the underlying risk in place.

3 Duties have gradually expanded informally without anyone reviewing scope.

Gradual, informal expansion is exactly the pattern this criterion exists to catch.

Week 1 Review current duties against verified scope for all clinical staff.

Week 2 Correct any mismatch found.

Week 3 Establish a periodic review schedule.

Ongoing Repeat scope reviews on the defined schedule.

Ask a staff member to describe their actual daily duties in detail.

A detailed description can reveal drift a job title alone wouldn't show.

Check non-physician clinical staff specifically.

Scope drift often goes unnoticed longest in less closely supervised roles.

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

REFERENCES

1. [41] International Organization for Standardization. ISO 9001:2015 — Quality management systems — Requirements. 5th ed. Geneva: ISO; 2015 — Clause 9.3 requires management review of the quality management system's performance at planned intervals, distinct from reactive incident response.

Reacting to individual incidents as they happen is necessary but not sufficient — without a periodic step back to review the whole picture, a slow decline across many small, individually unremarkable events can go unnoticed until it becomes a serious pattern. For a genuine solo practitioner, Adapted does not mean skipping this because there is no one to review with — it means blocking real, dedicated time, alone, on a fixed schedule, to look back through recent cases, complaints, and near-misses as a genuine reviewer of your own practice, not just as the clinician who lived through each one individually.

1 A review happens but only when leadership happens to have time, not on a fixed schedule.

An irregular pattern risks the review being deprioritised indefinitely during busy periods.

2 Trends are informally noticed but never formally analysed or documented.

Undocumented pattern recognition is hard to distinguish from coincidence.

3 Decisions are made during review but not tracked to completion afterward.

A decision without follow-through tracking often quietly doesn't happen.

Week 1 Establish a specific, regular interval for a genuine performance review.

Week 2 Build a simple trend-analysis method covering incidents, complaints, and quality data together.

Week 3 Define how review decisions will be tracked to completion.

Ongoing Hold the review on schedule and track action completion.

For Micro (solo) Block a specific, recurring date on your own calendar — quarterly is reasonable — and use that time to read back through the last quarter's incidents, complaints, and near-misses as a reviewer would, not as you experienced them in the moment.

Ask for the actual review schedule and minutes, not a description of intended practice.

Dated records are the only real evidence of a consistent, planned process.

Ask for a specific example of a decision that came from a review, not an incident.

This distinguishes genuine systematic review from incident-reactive management alone.

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

REFERENCES

1. [42] International Organization for Standardization. ISO 9001:2015 — Quality management systems — Requirements. 5th ed. Geneva: ISO; 2015 — Clause 6.2 requires quality objectives that are measurable, monitored, and communicated, distinct from general quality aspirations.

A general commitment to quality provides no way to know whether things are actually improving, staying flat, or quietly getting worse — specific, measurable objectives are what make quality something the clinic can actually manage, not just hope for. For a genuine solo practitioner, Adapted means the objective is written down and specific even though only one person will ever see it — a private, specific goal still counts, and still needs to be genuinely measurable, not a vague intention.

1 Objectives are set but not revisited until the following year.

Infrequent revisiting limits the ability to course-correct during the period.

2 Objectives are measurable but tracking happens informally without documentation.

Undocumented tracking is hard to distinguish from not tracking at all.

3 Leadership knows the objectives but they were never communicated to front-line staff.

Objectives staff don't know about can't meaningfully shape their daily work.

Week 1 Review current quality objectives, if any, for genuine specificity and measurability.

Week 2 Set or refine specific, measurable objectives for the coming period.

Week 3 Communicate objectives to relevant staff and establish a tracking method.

Ongoing Track progress and revisit objectives at defined intervals.

For Micro (solo) Write one or two specific, measurable objectives for the coming period, even though you're the only person who will track them — for example, a specific target for test-result turnaround time or patient complaint response time.

Ask for the actual objectives, with numbers or specific targets, not a general statement.

Specificity is what distinguishes a real objective from an aspiration.

Ask a front-line staff member if they know the current objective.

This reveals whether objectives genuinely reach beyond leadership.

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

REFERENCES

1. [43] International Organization for Standardization. ISO 9001:2015 — Quality management systems — Requirements. 5th ed. Geneva: ISO; 2015 — Clause 10.3 requires continual improvement of the quality management system's suitability, adequacy, and effectiveness, as a distinct requirement from corrective action on nonconformities.

Reacting only to incidents means the clinic only improves in response to something already having gone wrong — a genuine continual improvement process looks for opportunities to get better even where nothing has yet failed. For a genuine solo practitioner, Adapted means replacing team-based suggestion mechanisms with a real substitute — patient feedback is often the most honest and available source of improvement ideas when there's no colleague to raise them with you.

1 A suggestion channel exists but has never actually been used.

An unused channel may not be genuinely known or trusted by staff.

2 Improvement happens but is driven entirely by leadership, without staff input.

Front-line perspective often surfaces different opportunities than leadership sees.

3 A process exists on paper but the clinic cannot point to a real recent example.

A theoretical process and a genuinely functioning one are different things.

Week 1 Review current practice for any proactive, non-incident-driven improvement activity.

Week 2 Establish a specific staff suggestion channel if none exists.

Week 3 Define a process for evaluating and acting on improvement suggestions.

Ongoing Track and document real examples of proactive improvement.

For Micro (solo) Use patient feedback specifically as your improvement input channel — actively ask a few patients each month what could have gone better, and keep a simple, dated log of ideas this surfaces and what you actually changed as a result.

Ask for a real, recent example that wasn't triggered by an incident.

This is the clearest test of whether improvement is genuinely proactive.

Ask a front-line staff member how they'd suggest an improvement idea.

A confident, specific answer reveals whether the channel is genuinely known.