Accréditation Sans Frontières · ASF Health Standards 9.0
Standard 8 · Rehabilitation
6 criteria · base standard
Base standard. 6 criteria, of which 2 non-negotiable. Each criterion is numbered 8.Y, with its classification and verification questions.
Criteria
- 8.1 Individualised Rehabilitation Plan Based on Functional Assessment (NON-NEGOTIABLE)
- 8.2 Multidisciplinary Team Coordination (NON-NEGOTIABLE)
- 8.3 Patient and Family Goal-Setting and Education (CORE)
- 8.4 Progress Is Measured With Validated Functional Outcome Tools (CORE)
- 8.5 Equipment and Assistive Device Provision Matches Need (CORE)
- 8.6 Discharge and Community Reintegration Planning (STANDARD)
8.1 Individualised Rehabilitation Plan Based on Functional Assessment
NON-NEGOTIABLE
Every patient receiving rehabilitation services has an individualised plan built from a documented functional assessment, not a generic protocol applied regardless of the patient's specific impairment and baseline function.
VERIFICATION QUESTIONS
- Is a documented functional assessment performed before the rehabilitation plan is built, not a generic protocol applied by diagnosis alone?
Two patients with the same diagnosis can have very different functional starting points. - Is the plan individualised to that assessment, not a standard template with the patient's name filled in?
Check this by comparing several patients' plans to confirm the content differs, not only the names. - Is the plan reassessed and adjusted as the patient's function changes during the course of treatment?
A plan fixed at admission may no longer reflect the patient's progress weeks later.
8.2 Multidisciplinary Team Coordination
NON-NEGOTIABLE
Rehabilitation care is coordinated across the relevant disciplines — physical therapy, occupational therapy, speech-language therapy, rehabilitation medicine, nursing, as applicable to the patient — through a shared process, not separate disciplines working in isolation from each other.
VERIFICATION QUESTIONS
- Is there a shared coordination process
a joint case conference, a shared plan document — not just separate disciplines each documenting independently? — Isolated discipline-specific notes with no shared coordination point are a common failure. - Does coordination happen on a defined, recurring schedule, not only at admission and discharge?
A patient's course can change significantly between admission and discharge without interim coordination. - Can staff from different disciplines describe a specific instance where coordination changed the care plan?
Evidence the coordination process functions, not just exists as a scheduled meeting.
8.3 Patient and Family Goal-Setting and Education
CORE
Rehabilitation goals are set collaboratively with the patient and, where appropriate, family, in understandable terms, with the patient and family informed of realistic expectations — not goals set unilaterally by the clinical team.
VERIFICATION QUESTIONS
- Are goals documented as collaborative, with the patient's own input visible, not set unilaterally by staff?
A goal-setting record showing only clinical input, with no patient voice, suggests a one-way process. - Are realistic expectations communicated, not an overly optimistic picture that sets the patient up for disappointment?
Honest, calibrated communication, not false reassurance. - Is the patient able to describe their own rehabilitation goals in their own words when asked?
If the patient cannot articulate the goals, the collaborative process likely did not take place.
8.4 Progress Is Measured With Validated Functional Outcome Tools
CORE
Rehabilitation progress is tracked using a validated functional outcome measurement tool appropriate to the patient's condition, applied consistently at defined intervals, not relying on informal clinical impression alone.
VERIFICATION QUESTIONS
- Is a validated, recognised outcome tool used, not an informal, ad hoc progress note?
A validated tool provides a consistent, comparable measure; informal notes do not. - Is the tool applied at defined, consistent intervals, not sporadically whenever convenient?
Irregular measurement makes progress tracking difficult. - Do outcome measurements inform changes to the treatment plan, or are they recorded without influencing care?
Measurement that does not feed back into the plan is documentation for its own sake.
8.5 Equipment and Assistive Device Provision Matches Need
CORE
Assistive devices and equipment — mobility aids, orthotics, adaptive equipment — are assessed, fitted, and provided to match the patient's actual functional need, with patient and caregiver trained in correct use before discharge.
VERIFICATION QUESTIONS
- Is equipment provision based on a documented individual assessment, not a default or convenience-driven choice?
Equipment that is readily in stock, rather than suited to the patient's need, is a specific, checkable gap. - Are patient and caregiver trained in correct use before discharge, not just handed the equipment?
Equipment without training in its use risks being unsafe or unused. - Is there a documented process for follow-up if the equipment later proves a poor fit?
A fitting assessed once at discharge may not remain appropriate as the patient's needs evolve.
8.6 Discharge and Community Reintegration Planning
STANDARD
Discharge planning for rehabilitation patients begins early in the course of treatment and addresses home environment, caregiver support, community resources, and follow-up therapy — not a last-minute checklist completed at the point of discharge.
VERIFICATION QUESTIONS
- Does discharge planning begin early in the treatment course, not only in the final days before discharge?
Early planning allows time to address gaps, such as a home environment needing modification. - Does the plan specifically address the patient's actual home environment and caregiver support, not generic discharge instructions?
A home with stairs and no support, for a patient with limited mobility, is a specific, checkable risk. - Is follow-up therapy or community resource connection arranged, not just recommended verbally?
A verbal recommendation with no actual referral or appointment often does not result in follow-through. ————————————————————