Accréditation Sans Frontières · ASF Health Standards 9.0
Standard 3 · Environment & Shared Spaces
8 criteria · base standard
Base standard. 8 criteria, of which 5 non-negotiable. Each criterion is numbered 3.Y, with its classification and verification questions.
Criteria
- 3.1 Water Supply Is Safe and Monitored (NON-NEGOTIABLE)
- 3.2 Medical Equipment Is Maintained on Schedule (NON-NEGOTIABLE)
- 3.3 Shared Spaces Are Clean (CORE)
- 3.4 Facility Risks Are Tracked in One Integrated Register (NON-NEGOTIABLE)
- 3.5 An Environmental Sustainability Programme Is Active (CORE)
- 3.6 Facility Signage Is Complete Throughout the Building (NON-NEGOTIABLE)
- 3.7 Fault Prevention Is Planned, Not Only Repaired (NON-NEGOTIABLE)
- 3.8 Endoscopy Equipment Is Safe to Use and Properly Reprocessed (CORE)
3.1 Water Supply Is Safe and Monitored
NON-NEGOTIABLE
Water quality is tested on a defined schedule and a contingency plan exists for interruption — not an assumption that municipal supply is automatically safe.
VERIFICATION QUESTIONS
- Is water quality tested on a defined, regular schedule, with records kept?
"It is municipal water, it is fine" is an assumption, not a verified fact. - Is there a documented contingency plan for water supply interruption?
A plan written after the fact, during an actual interruption, is not a contingency plan. - Are test results reviewed and acted on, not just filed?
A concerning result that nobody reads is no better than not testing at all.
3.2 Medical Equipment Is Maintained on Schedule
NON-NEGOTIABLE
A maintenance programme covers all clinical equipment on a defined schedule, and faulty equipment is removed from use, not kept in service pending eventual repair.
VERIFICATION QUESTIONS
- Is there a documented maintenance schedule covering all clinical equipment?
Not equipment maintained "as needed" or reactively — a defined, proactive schedule. - Is faulty equipment removed from use, not kept in service while awaiting repair?
A tag or note is not sufficient if the equipment remains physically accessible for use. - Is there a named person or role responsible for the maintenance programme?
Responsibility spread across nobody in particular usually means it happens inconsistently.
3.3 Shared Spaces Are Clean
CORE
Shared clinical and waiting areas are cleaned on a documented schedule, with cleanliness verified by more than a visual check on the day of assessment.
VERIFICATION QUESTIONS
- Is there a documented cleaning schedule for shared spaces, with records kept?
Not a general statement that cleaning happens — a specific, dated schedule. - Is cleaning verified through more than a visual check, such as a defined inspection process?
Visual cleanliness and actual microbial cleanliness are not the same thing. - Are high-touch surfaces specifically included in the schedule, not just visible floor and surface areas?
Door handles, rails, and switches are easy to overlook relative to more visible surfaces.
3.4 Facility Risks Are Tracked in One Integrated Register
NON-NEGOTIABLE
Water safety, fire safety, equipment maintenance, and other facility risks are tracked together in one reviewed risk register — not as separate, disconnected checklists that nobody views as a whole picture.
VERIFICATION QUESTIONS
- Do water safety, fire safety, and equipment maintenance data feed into one integrated risk register, not separate untracked lists?
A single place where facility leadership can see the whole risk picture, not scattered logs nobody reviews together. - Is the register reviewed on a defined schedule by facility leadership, not just maintained by individual department staff?
Review at a level that can act across domains, not only within one narrow area. - Does the register prioritise risks, not just list them?
A risk management tool ranks what needs attention first, rather than treating every item as equally urgent.
3.5 An Environmental Sustainability Programme Is Active
CORE
The facility has a specific, documented environmental sustainability programme — covering energy use, waste reduction, and resource consumption — with tracked progress, not a general statement of environmental awareness with no measurable action behind it.
VERIFICATION QUESTIONS
- Is there a specific, written sustainability programme covering energy, waste, and resource use?
A specific, documented programme, not a general statement of environmental values. - Is progress tracked against defined, measurable targets?
Trackable metrics, not an assumption that good intentions are sufficient. - Is there a named person or team responsible for the programme?
Specific ownership, not diffuse responsibility that belongs to nobody in particular.
3.6 Facility Signage Is Complete Throughout the Building
NON-NEGOTIABLE
Evacuation routes, emergency exits, restrooms, and procedure or department doors are clearly and consistently signed throughout the facility — not only the entrance and reception area covered under wayfinding, and not assumed adequately covered by evacuation drills alone.
VERIFICATION QUESTIONS
- Are evacuation routes and emergency exits clearly signed throughout the facility, not only near the main entrance?
Comprehensive coverage — deep corridors, upper floors, less-trafficked areas — not concentrated near reception. - Are restrooms and procedure or department doors clearly and consistently labelled?
Consistent labelling convention throughout, not signage that varies by department or era of installation. - Is signage periodically checked for damage, obstruction, or fading, not installed once and assumed permanent?
Signage degrades over time and needs the same ongoing attention as any other safety measure.
3.7 Fault Prevention Is Planned, Not Only Repaired
NON-NEGOTIABLE
Power, water, medical gases, ventilation and clinical information systems are identified as critical, each has a planned prevention and back-up arrangement, and failures are recorded and analysed so that the same fault does not recur.
VERIFICATION QUESTIONS
- Is every critical service (power, water, medical gases, ventilation, clinical information systems) identified, with a named owner and a documented back-up arrangement?
A service that nobody owns fails without warning. - Is there a planned maintenance and testing schedule for these services, with records kept?
A back-up generator that has never been tested is not a back-up. - Are failures recorded and analysed, and is each analysis followed by a preventive change?
A failure that is repaired and forgotten will happen again.
3.8 Endoscopy Equipment Is Safe to Use and Properly Reprocessed
CORE
Endoscopes and endoscopic equipment are maintained, tested and reprocessed to a documented standard before each use, and records allow every use to be traced to the device and the reprocessing cycle.
VERIFICATION QUESTIONS
- Is every endoscope tested and maintained on a schedule, with the results recorded?
A leaking endoscope can carry infection from one patient to the next. - Is reprocessing carried out to a documented, validated procedure, and is each cycle recorded?
A cycle that cannot be shown on record cannot be shown to be done. - Can each patient's procedure be traced to the device used and its reprocessing cycle?
Traceability is the only way to find the source when an infection appears. ————————————————————