Governance & Management

MANDATORY

13 criteria

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

REFERENCES

Without a functioning governing body, there is no accountability mechanism above clinical leadership for safety and quality. A board that exists on paper but has no real named members or documented authority provides the appearance of oversight without its substance.

1 The board meets regularly but the quality agenda item is a formality with no real discussion.

Presence on the agenda doesn't guarantee genuine engagement with the content.

2 Minutes exist but record attendance only, not actual decisions taken.

A record of who was present says nothing about what was actually decided.

3 One board member drives all quality engagement, with others largely passive.

Genuine collective oversight requires more than one engaged individual carrying the whole function.

Week 1 Review recent board minutes for genuine quality discussion versus formality.

Week 2 Add or reinforce a standing quality and safety agenda item with real data presented.

Week 3 Identify the reporting pathway gap between incident/quality data and board-level visibility, if one exists.

Ongoing Track board-level follow-up actions to closure, not just to being raised.

Ask for the last four sets of minutes, not the charter alone.

A polished charter proves nothing about actual practice.

Interview a board member alone, not with the CEO present.

If a board member cannot answer without looking to the CEO, oversight is not independent in practice, whatever the bylaws say.

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

REFERENCES

A strategic plan that doesn't influence real resourcing decisions is a wall decoration, not a plan. The test isn't whether a plan exists but whether decisions about money, staffing, and priorities can be traced back to it.

1 A plan exists and is well written but was never actually communicated to front-line staff.

Quality of the document doesn't matter if it never reaches the people expected to align with it.

2 The plan states priorities but the annual budget process runs independently of it.

Two parallel processes that don't reference each other produce a plan with no real teeth.

3 Leadership can trace decisions to the plan; front-line staff cannot see the connection.

Strategic alignment that exists only at the top doesn't reach the level where most decisions actually get executed.

Week 1 Review the current plan for specificity and whether recent resourcing decisions reference it.

Week 2 Communicate the plan's core priorities directly to front-line staff, not just leadership.

Week 3 Link the next resourcing or budget decision explicitly and visibly to a stated strategic priority.

Ongoing Revisit the plan on a fixed schedule, not only when it happens to come up.

Ask staff in different departments the same question separately.

Consistency across independent answers reveals genuine organisational alignment.

Ask for one specific recent decision and trace its rationale.

A real, traceable example is worth more than a general assurance the plan guides decisions.

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

REFERENCES

Policy-practice gaps are consistently identified in healthcare quality literature as a distinct failure mode from policy absence — the existence of a written policy is not evidence of its implementation.

A policy nobody follows provides the appearance of governance without its function. The real question isn't whether a policy document exists — it's whether staff behaviour actually reflects it, which is a fundamentally different, harder thing to verify.

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

Established habit reinforces old policy adherence; new policies need active reinforcement to take hold.

2 An adherence check exists but only samples a small, easily-prepared subset of practice.

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

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

Identification without follow-through leaves the underlying gap unresolved.

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

Week 2 Establish or reinforce a genuine adherence-checking mechanism, not just document review.

Week 3 Build a tracked resolution process for any policy-practice gap identified.

Ongoing Rotate which policies get checked, avoiding a predictable, easily-prepared audit pattern.

Ask about application, not existence.

"Do you know this policy exists" and "how do you actually apply it" surface very different answers.

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

Direct observation reveals gaps document review alone cannot.

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

REFERENCES

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 of other patients provides no real protection. Privacy has to be built into the physical and behavioural fabric of the facility, not just stated as an intention.

1 Physical privacy is good in some areas but overlooked in others, like corridors or shared bays.

Privacy protection is often strongest where it was deliberately designed and weaker in less-considered spaces.

2 Staff are conscientious about privacy when reminded but inconsistent otherwise.

Habitual practice is a different, more reliable thing than practice prompted by reminder.

3 Curtains or private spaces exist but aren't consistently used under time pressure.

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

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

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

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

Ongoing Spot-check physical privacy periodically, including in less-considered shared spaces.

Walk the space as a visitor would, checking what's actually visible or audible.

A staff member's familiar routine can make an obvious privacy gap invisible to them.

Ask staff for specific examples of their own privacy practices.

Specific, concrete habits reveal genuine internalisation better than reciting the policy.

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

REFERENCES

Medical record completeness auditing is a recognised quality assurance practice specifically because template existence alone does not guarantee consistent completion in real clinical practice.

An incomplete record is a specific, quiet risk — the information a future clinician needs might simply not be there, discovered only at the moment it's needed most. Regular auditing is what catches completeness gaps before they matter clinically, rather than after.

1 Audits happen but only sample a small, non-representative set of records.

A narrow sample can miss where real completeness gaps concentrate.

2 Completeness is checked for structural fields but not for genuine clinical content quality.

A record can be structurally complete while still lacking substantively useful clinical detail.

3 Gaps are found and noted but resolution isn't consistently tracked to closure.

Identification without follow-through leaves the same underlying risk unaddressed.

Week 1 Review the current mandatory elements list and recent audit practice, if any exists.

Week 2 Establish or reinforce a genuine, regular completeness audit process.

Week 3 Build a gap resolution tracker so identified issues are actually closed.

Ongoing Widen the audit sample periodically to avoid a narrow, predictable pattern.

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

Dated findings are the only real evidence a genuine audit occurs.

Check whether a past identified gap was actually resolved.

Resolution tracking reveals whether the audit process has real teeth.

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

REFERENCES

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.

Patient data security failures compound the harm of any breach with a loss of trust that can outlast the immediate incident. Access controls and a real, rehearsed breach response are what limit both the likelihood of a breach and the damage if one occurs, and neither requires expensive enterprise systems to be genuine.

1 Access controls exist for electronic records but not consistently for physical files.

Security attention often concentrates on digital systems while physical record access remains loosely controlled.

2 A breach response plan exists but has never been reviewed since it was written.

An unreviewed plan may not reflect current systems, staff, or actual risk.

3 Access controls are correctly configured but not periodically re-reviewed as staff roles change.

Role changes and departures can leave stale access permissions unless actively managed.

Week 1 Review current access controls against actual staff roles for any over-broad access.

Week 2 Draft or review the breach response plan for specificity and actionable steps.

Week 3 Brief relevant staff on their role in the breach response process.

Ongoing Review access control assignments periodically as staff roles change.

Check physical record access, not only electronic systems.

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

Ask when the breach plan was last reviewed, not just whether it exists.

A plan's age relative to current systems and staff matters as much as its existence.

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

REFERENCES

Health record retention requirements vary by jurisdiction and are legally defined precisely because both premature destruction and indefinite retention carry distinct, documented risks.

Records kept too briefly can be destroyed before they're legally or clinically needed again; records kept indefinitely accumulate unnecessary risk and cost. A retention policy aligned to the actual legal requirement is what gets this balance right, rather than guessing.

1 A policy exists but was written years ago and never checked against a legal requirement update.

Legal requirements can change, and a policy set once can quietly become outdated.

2 Retention periods are correct for most record types but a specific category was overlooked.

Comprehensive-looking policies can still miss a specific record type with different legal requirements.

3 Disposal happens but isn't consistently documented.

Undocumented disposal leaves no verifiable evidence the process actually occurred as required.

Week 1 Review the current retention policy against the actual legal requirement for this jurisdiction.

Week 2 Correct any misalignment found and update the policy accordingly.

Week 3 Establish a documented, secure disposal process for records past retention.

Ongoing Recheck legal requirement alignment periodically, as regulations can change.

Ask for the specific legal citation the retention period is based on.

A specific reference, or its absence, reveals whether this was genuinely checked or assumed.

Check disposal documentation, not just the retention policy itself.

A correct policy on paper doesn't guarantee correct, documented execution.

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

REFERENCES

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 barrier to reporting is almost always fear of blame, not the mechanics of the form — which means the real work is building psychological safety around reporting, not just building the system itself.

1 Reporting happens for minor incidents but staff hesitate to report anything involving their own error.

Psychological safety often varies by perceived personal exposure, not uniformly across incident types.

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

Hierarchy can create very different real experiences of psychological safety within the same facility.

3 A non-punitive policy exists on paper but staff describe a past incident where reporting led to real consequences.

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

Week 1 Review reporting volume trends and identify any concerning drop or pattern.

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

Week 3 Address any specific past incident or perception undermining psychological safety directly and visibly.

Ongoing Track reporting volume as an ongoing indicator, investigating any significant drop.

Ask junior staff specifically, not only senior staff.

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

Ask about reporting one's own error specifically, not just witnessing someone else's.

Self-reporting confidence is usually the harder, more revealing test of genuine psychological safety.

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

REFERENCES

Root cause analysis methodology is a well-established patient safety practice specifically because surface-level incident review, without deeper systemic examination, is consistently associated with recurrence of preventable events.

An incident review that identifies what happened without examining the underlying system conditions that allowed it will likely see the same incident recur. Root cause analysis exists specifically to find the systemic factors a surface-level review misses.

1 RCA is conducted for the most severe incidents but not consistently applied to moderately serious ones.

A narrower-than-intended threshold for triggering RCA can leave real systemic issues unexamined.

2 Action plans are written but implementation isn't consistently tracked to actual completion.

A good plan on paper doesn't guarantee the underlying system issue actually got fixed.

3 RCA identifies contributing factors but stops short of genuinely systemic root causes.

A surface-level analysis that names immediate causes without examining deeper conditions misses much of RCA's value.

Week 1 Review recent serious incidents for evidence of genuine RCA versus brief incident notes.

Week 2 Ensure RCA methodology is applied consistently against a clear, defined severity threshold.

Week 3 Build a tracked action plan process ensuring RCA findings translate into completed changes.

Ongoing Audit action plan completion rates periodically.

Ask for a completed RCA example, not a description of the methodology.

A real example reveals whether the analysis goes genuinely systemic or stays surface-level.

Check whether action items from past RCAs were actually completed.

Completion tracking is where good analysis either translates into real prevention or doesn't.

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

REFERENCES

Safety culture surveys are a recognised patient safety measurement practice specifically because staff silence is an ambiguous signal that can indicate either genuine safety or suppressed concern, and only direct measurement distinguishes between them.

The absence of complaints is not evidence of a healthy safety culture — it may equally reflect staff who have learned that raising concerns doesn't help, or carries risk. A validated survey measures the thing directly, rather than inferring it from silence.

1 A survey is conducted but response rates are low, undermining result reliability.

Low participation can reflect the same trust issues the survey is trying to measure.

2 Results are reviewed by leadership but not communicated back to staff.

A closed feedback loop, invisible to staff, doesn't build the trust genuine improvement requires.

3 Action is taken on some findings but not others, without a clear rationale communicated.

Selective, unexplained follow-up can read to staff as results not being taken seriously.

Week 1 Review the current survey tool for validation and the administration schedule for regularity.

Week 2 If response rates are low, investigate why and address barriers to participation.

Week 3 Establish a process to communicate results and planned actions back to staff.

Ongoing Track whether survey-driven actions are visible and completed, and repeat on schedule.

Ask staff directly whether they believe the survey leads to real change.

Staff perception of genuine impact is the real test, not survey administration alone.

Check response rates, not just that a survey was sent.

Low participation can itself be a safety culture signal worth investigating.

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

REFERENCES

Ongoing patient experience measurement, distinct from post-discharge complaint mechanisms, is an established quality improvement practice in international hospital accreditation frameworks, providing earlier and more representative signal than complaint-based feedback alone.

A complaint channel captures what went wrong badly enough for a patient to formally raise it after leaving. Continuous experience measurement during the stay itself catches smaller, earlier signals — the kind that, addressed in the moment, prevent a bigger problem from developing at all.

1 Feedback is collected but response rates are low, limiting how representative the picture actually is.

Low participation can mean the loudest or most engaged voices dominate, not a representative signal.

2 Feedback is reviewed by leadership but rarely translated into a visible, communicated change.

A closed feedback loop that doesn't visibly act on input can erode patient willingness to participate over time.

3 Collection happens for inpatient stays but not for shorter outpatient or day-procedure visits.

Shorter encounters still shape a patient's real experience and deserve the same measurement discipline.

Week 1 Review current patient experience measurement, if any, for systematic reach versus self-selected feedback.

Week 2 Establish or strengthen a structured, ongoing feedback mechanism during the stay.

Week 3 Build a defined review process ensuring feedback actually informs improvement decisions.

Ongoing Track response rates and periodically communicate real changes made in response to feedback.

Ask for a specific, real example of a change made from feedback.

A real example reveals genuine responsiveness better than a description of the collection process.

Check response rates, not just that a feedback mechanism exists.

Low participation can undermine how representative the collected picture actually is.

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

REFERENCES

Access to clinical ethics consultation is an established structural requirement in major international hospital accreditation and governance frameworks, recognising that individual clinicians should not be left to resolve genuine ethical complexity without institutional support.

Genuinely difficult ethical situations — conflicting patient and family wishes, uncertain capacity, resource allocation dilemmas — arise in any hospital, and staff facing them without structured support are left to navigate real moral complexity alone, under pressure, in the moment it matters most.

1 A resource exists but is only accessible during business hours, leaving urgent after-hours dilemmas unsupported.

Ethical dilemmas don't confine themselves to convenient hours, and a resource that assumes they will has a real coverage gap.

2 Senior staff know how to access consultation; junior staff facing the same dilemmas often don't.

Awareness concentrated at senior levels doesn't help staff who most need support in the moment.

3 A committee exists on paper but hasn't convened or been consulted in a very long time.

An inactive resource functions similarly to no resource at all when a real case actually arises.

Week 1 Review current access to ethics consultation, if any, for real structure versus policy statement.

Week 2 Establish or reinforce a genuinely accessible process, including after-hours coverage.

Week 3 Brief all clinical staff, not only senior staff, on how to access it.

Ongoing Review whether the process is genuinely being used when needed, not just theoretically available.

Ask a junior staff member how they'd access ethics support, not a department head.

This reveals whether awareness genuinely reaches the staff most likely to face difficult cases directly.

Ask about after-hours access specifically.

A resource available only during business hours has a real, common gap worth checking directly.

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

REFERENCES

Patient and family engagement in governance and quality structures, distinct from feedback mechanisms alone, is an established element of patient-centred care frameworks in international hospital accreditation and governance literature.

A facility can measure patient experience thoroughly and still make every actual governance and quality decision without a patient or family voice genuinely present in the room. Surveys and complaints are valuable, but they're filtered through staff interpretation before reaching a decision-maker — a structured patient or family role changes what gets heard and how it's weighed.

1 A representative role exists but the position has been vacant for some time without being filled.

A defined role that isn't actually occupied provides no real, current voice.

2 The representative attends but discussions move quickly in technical or clinical language that limits genuine participation.

Presence without genuine accessibility to the discussion doesn't provide real influence.

3 Patient input shapes minor operational decisions but rarely reaches larger strategic or safety discussions.

Influence confined to smaller matters misses the discussions where patient perspective often matters most.

Week 1 Review current governance and quality review structure for any existing patient or family voice.

Week 2 Recruit or confirm a patient or family representative for a genuine, structured role.

Week 3 Brief the representative and the governance team on genuine participation expectations, not passive attendance.

Ongoing Track and document specific instances where patient or family input has shaped decisions.

Ask for a specific, real example of influence, not a description of the role's existence.

A concrete instance reveals whether this is genuine participation or a symbolic seat.

Check whether the role is currently filled, not just defined in principle.

A vacant position provides no real, current voice regardless of how it's written into governance structure.