Primary Health Clinic Standards

Every registered patient is formally empaneled — assigned to a specific, named clinician or care team responsible for their ongoing care — not simply added to a general patient list with no defined, accountable relationship.

Full guidance for 1.1 →

1. Is every registered patient formally empaneled to a specific, named clinician or care team? — A real, specific assignment, not a general patient list with no defined accountability.

2. Is empanelment genuinely sensitive to patient and family preference, not assigned arbitrarily? — Genuine consideration of preference, not a mechanical assignment process alone.

3. Can a patient or staff member identify exactly who this patient's primary clinician is, without ambiguity? — A clear, unambiguous answer, not uncertainty about who is actually responsible.

A patient's relevant medical history, prior visits, and ongoing issues are genuinely reviewed and actively used at each visit — not treated as a fresh encounter each time, with the clinician relying only on what the patient happens to mention that day.

Full guidance for 1.2 →

1. Is a patient's relevant history genuinely reviewed before or during each visit, not relied on solely from what they mention that day? — Real, active review of the actual record, not passive reliance on patient recall alone.

2. Are ongoing issues from prior visits actively followed up, not lost between encounters? — Genuine, tracked follow-through, not issues that quietly drop between visits.

3. Can the clinician describe specific, relevant history for a patient without the patient having to repeat it? — Genuine, demonstrated knowledge, not dependence on the patient re-explaining their own history each time.

The practice actively measures its own continuity of care — the proportion of a patient's visits that are genuinely with their own empaneled clinician or team — not assuming continuity is adequate without ever actually checking.

Full guidance for 1.3 →

1. Does the practice actively calculate a real continuity measure, not assume continuity is adequate? — A genuine, calculated measure, not an unverified assumption.

2. Is this measure reviewed regularly, not calculated once and forgotten? — Genuine, ongoing review, not a one-time calculation.

3. When continuity is found to be low for a specific patient or pattern, is there a genuine response? — Real, active response to a low result, not a measure tracked without consequence.

Patient registration captures genuinely relevant information for ongoing primary care — chronic conditions, family history, social context affecting health — not only administrative and billing information, treated as sufficient on its own.

Full guidance for 1.4 →

1. Does registration genuinely capture chronic conditions, family history, and relevant social context, not only administrative details? — Real, clinically relevant information, not billing and contact details alone.

2. Is this information actively used to inform the patient's early care, not collected and left unused? — Genuine, early use of registration information, not documentation without follow-through.

3. Is registration information genuinely updated over time, not treated as fixed from the first visit? — Real, ongoing updates, not information that grows stale as the patient's circumstances change.

A patient has a genuine, defined way to reach their own empaneled clinician or care team for an ongoing issue — not only the option of whoever happens to be available that day, with no real path back to the clinician who actually knows their history.

Full guidance for 1.5 →

1. Does a patient have a genuine, defined way to reach their own empaneled clinician or team? — A real, specific pathway, not default routing to whoever is available.

2. Is this pathway genuinely known to patients, not just theoretically available? — Real, communicated awareness, not an option patients don't know exists.

3. When the patient's own clinician genuinely isn't available, is there a defined handoff that preserves relevant history? — A real, structured handoff, not a complete loss of continuity when the usual clinician is out.

Every patient receives a genuine, understandable explanation of their rights — privacy, dignity and respect, confidentiality of their information, personal safety, how consent is granted, and the explicit right to refuse any test or treatment — not a notice buried in registration paperwork nobody actually reads. The explanation recognises the patient’s cultural and spiritual preferences, including access to care consistent with them.

Full guidance for 1.6 →

1. Does every patient receive a genuine, understandable explanation of their rights, not just a form to sign? — A real explanation that registers, not paperwork signed without discussion.

2. Can a patient asked directly describe at least one of their rights, including the right to refuse treatment, in their own words? — Tests genuine understanding, not just that disclosure technically occurred.

3. Is the right to refuse genuinely honoured in practice, with staff able to describe what happens when a patient exercises it? — A real, functioning right, not a line in a form with no defined practice behind it.

4. Is there a real, accessible way for a patient to request accommodation of their cultural or spiritual needs? — A specific, usable process a patient can actually invoke, not only general staff awareness.

When a patient is first empaneled, a qualified clinician performs a genuine comprehensive assessment — not only the condition that prompted the visit — drawing in other relevant disciplines where the patient’s needs call for it, and sets explicit goals for their ongoing care that the patient genuinely helped shape, not goals decided for them and only announced.

Full guidance for 1.7 →

1. Does empanelment include a genuine comprehensive assessment, not only a note about the presenting complaint? — A real, broader evaluation at the start of the relationship, not only the specific reason for that day’s visit.

2. Is the assessment performed by a genuinely qualified clinician, with other relevant disciplines drawn in where the patient’s needs call for it? — A named, qualified clinician, with real referral or consultation when complexity warrants it.

3. Does the patient’s record state explicit goals for their ongoing care, and was the patient genuinely involved in setting them? — A real, stated goal and genuine involvement, not a plan decided for the patient and only communicated to them.

The practice uses a systematic tracking process to identify which evidence-graded preventive services each patient is due for, based on age, sex, and risk factors — not relying on a clinician remembering to consider this during a visit already focused on the patient's presenting concern.

Full guidance for 2.1 →

1. Does the practice use a systematic process to identify which preventive services each patient is due for? — A real, structured tracking system, not reliance on the clinician remembering during a busy visit.

2. Does this tracking genuinely account for the patient's actual age, sex, and risk factors, not a generic checklist? — Individualized, accurate tracking, not a one-size-fits-all list.

3. Is the tracking system actively used at or before each visit, not maintained separately from actual care? — Genuine, integrated use, not a system that exists without informing real encounters.

The practice proactively offers grade A and B preventive services when a patient is due — flagged, discussed, and offered as a matter of standard practice — not delivered only when a patient happens to specifically ask about a particular screening or vaccination.

Full guidance for 2.2 →

1. Are grade A and B preventive services proactively offered when a patient is due, not only when specifically requested? — Genuine, proactive offering, not passive availability dependent on patient initiative.

2. Does proactive offering happen consistently regardless of the patient's apparent health literacy or assertiveness? — Equal, consistent proactive practice, not dependent on how informed or confident a specific patient seems.

3. Is there real evidence that proactive offering actually results in higher completion, not just occurs without measurable effect? — Genuine, measurable impact, not an assumption that offering alone is sufficient.

The practice actively measures its own completion rates for key preventive screenings across its patient panel, with a genuine response when rates fall short — not a general sense that screening happens without ever actually checking the real numbers.

Full guidance for 2.3 →

1. Does the practice actively measure its own completion rates for key preventive screenings across its panel? — Real, calculated completion data, not a general assumption of adequacy.

2. Is there a genuine response when completion rates for a specific screening fall short? — Real, active improvement effort, not a rate tracked without consequence.

3. Is completion measured for the full eligible panel, not just patients who happen to attend preventive-focused visits? — Genuine, full-panel measurement, not a skewed sample of already-engaged patients.

For preventive services carrying genuine, documented tradeoffs between benefit and harm — such as lung cancer screening — the practice conducts real shared decision-making with the patient, not presenting the service as an automatic, default recommendation identical to lower-tradeoff screenings.

Full guidance for 2.4 →

1. Does the practice conduct genuine shared decision-making for screenings with real, documented tradeoffs? — A real, substantive conversation, not the service presented as an automatic default.

2. Does this conversation genuinely convey both potential benefits and potential harms, not benefits alone? — Balanced, honest information, not a one-sided presentation favoring screening.

3. Can a patient who underwent such screening explain back the genuine tradeoffs they were told about? — Tests genuine understanding, not just that a conversation technically occurred.

Every patient's immunization status is actively tracked against the current recommended schedule, with any identified gap actively addressed — not assumed current because no concern was raised, or left to the patient to remember and request.

Full guidance for 2.5 →

1. Is immunization status actively tracked against the current recommended schedule for every patient? — Real, active tracking, not an assumption of currency without verification.

2. Is an identified gap actively addressed, not just noted and left for the patient to raise? — Genuine, active follow-through, not passive documentation of a known gap.

3. Is tracking checked at any visit, not only during a visit specifically scheduled for immunization? — An active check at any opportunity, not limited to a narrow visit type.

Every patient with a chronic condition — diabetes, hypertension, and other ongoing conditions — is entered into an active disease registry that tracks their status between visits, not managed only reactively during whatever visit happens to occur.

Full guidance for 3.1 →

1. Is every patient with a chronic condition entered into an active registry tracking their status? — A real, maintained registry, not management limited to whatever happens to come up during a visit.

2. Does the registry track status between visits, not only reflect data from the most recent encounter? — Genuine, ongoing tracking, not a static snapshot from the last visit alone.

3. Is the registry actively used to inform care, not maintained as a record separate from actual practice? — Real, integrated use, not documentation disconnected from real clinical decisions.

Chronic disease control is measured against specific, evidence-based targets — HbA1c below 7.0 percent for diabetes, blood pressure below 130/80 mmHg for hypertension — with the actual result documented, not a general sense that a patient seems to be doing better without a specific, measured number.

Full guidance for 3.2 →

1. Is chronic disease control measured against specific, evidence-based numeric targets, not general impression? — A specific, documented number against a defined target, not a general sense of improvement.

2. Is the actual result documented for each patient, not assumed from overall trend? — A real, specific documented result, not an inference from general direction of change.

3. Is the practice's own aggregate control rate calculated, not just individual results recorded without a genuine summary view? — A real, calculated practice-level rate, not only scattered individual data points.

The practice proactively identifies patients with a chronic condition who are overdue for testing or follow-up — particularly those with poor control — and actively reaches out to them, not waiting passively for the patient to schedule their own next visit.

Full guidance for 3.3 →

1. Does the practice proactively identify patients with a chronic condition who are overdue for testing or follow-up? — Real, active identification, not passive awareness that some patients may be overdue.

2. Is there a specific, active outreach process for these patients, not just identification without follow-through? — Genuine outreach, not identification that doesn't lead to real contact.

3. Are patients with poor control specifically prioritized in this outreach, not treated the same as those with good control? — Genuine prioritization of the highest-risk patients, not undifferentiated outreach.

Chronic disease management genuinely involves the full care team — nurses, pharmacists, or other appropriate team members, not the physician alone — with real, coordinated roles, not the physician bearing the entire ongoing management burden without support.

Full guidance for 3.4 →

1. Does chronic disease management genuinely involve the full care team, not the physician alone? — Real, coordinated team involvement, not physician-only management.

2. Do team members have specific, defined roles in chronic disease management, not undefined or overlapping responsibility? — Clear, specific role definition, not ambiguous shared responsibility that no one actually owns.

3. Is there real evidence that team-based involvement is genuinely improving control rates, not just present without measurable effect? — Genuine, measurable impact, not team involvement without demonstrated benefit.

When a patient's chronic disease control falls short of the defined target, medication or treatment adjustment follows a specific, defined process within a reasonable timeframe — not left unchanged indefinitely simply because the patient hasn't raised a concern.

Full guidance for 3.5 →

1. Does treatment adjustment follow a specific, defined process when a patient's control falls short of target? — A real, defined process, not indefinite continuation of unchanged treatment.

2. Does adjustment happen within a reasonable, defined timeframe, not delayed indefinitely? — A specific, genuine timeframe, not an open-ended delay.

3. Is there defined follow-up after a treatment adjustment to confirm it's actually working? — Real, scheduled follow-up, not an adjustment made without checking whether it succeeded.

Staff performing patient intake and registration — not only the treating clinician — are trained to recognise defined red flag symptoms and immediately escalate, with a specific process for taking the patient back for urgent assessment right away, not left waiting in a normal queue.

Full guidance for 4.1 →

1. Are staff performing intake and registration specifically trained to recognise defined red flag symptoms? — Genuine, specific training for intake staff, not a responsibility left only to the clinician.

2. Is there a specific, immediate escalation process when a red flag is recognised at intake? — A real, immediate process, not a patient left in the normal queue despite a recognised red flag.

3. Is there a specific, ready space for a patient identified with a potential emergency at intake? — A real, dedicated, ready space, not an improvised response when a red flag is identified.

The practice actively measures whether patients requesting a genuine same-day need can actually be seen that day, with a specific, tracked target — not an assumption that same-day access is adequate without ever checking real appointment availability against real demand.

Full guidance for 4.2 →

1. Does the practice actively measure whether genuine same-day requests are actually accommodated that day? — Real, calculated measurement, not an assumption of adequacy.

2. Is there a specific, defined target for same-day access, not a vague sense that most patients get seen? — A specific, tracked target, not an undefined general impression.

3. When same-day access falls short of target, is there a genuine response, not a measure tracked without consequence? — Real, active response to a shortfall, not passive tracking alone.

Telephone or remote triage of patients requesting same-day care follows a structured, validated protocol — not the individual judgement of whoever happens to answer the phone, applied inconsistently from one call to the next.

Full guidance for 4.3 →

1. Does telephone or remote triage follow a structured, validated protocol, not individual judgement alone? — A real, structured protocol, not inconsistent practice dependent on who answers the call.

2. Is the protocol consistently used across different staff members conducting triage? — Genuine, consistent application, not a protocol used by some staff but not others.

3. Does the protocol specifically prompt for red flag symptoms, not rely on the patient volunteering concerning details? — Active, structured questioning for red flags, not passive reliance on what the patient happens to mention.

When a patient's presentation is atypical or overlaps with a benign condition, the clinician genuinely considers serious alternative diagnoses before defaulting to a benign explanation — not treating overlap with common, self-limiting illness as sufficient reason to rule out something more serious.

Full guidance for 4.4 →

1. Does the clinician genuinely consider serious alternative diagnoses for an atypical or overlapping presentation? — Real, active consideration, not immediate default to the more common, benign explanation.

2. Is there a specific process for documenting why a serious alternative was considered and ruled out? — A real, documented reasoning process, not an assumption reflected only in the final diagnosis.

3. Is there a defined safety-net process — return advice, follow-up — for a patient whose presentation remains uncertain? — A real, defined safety-net, not the patient sent away with no clear guidance if symptoms don't resolve as expected.

The practice maintains a specific, dedicated process and space for a patient who deteriorates or presents in genuine crisis while at the clinic — emergency equipment checked and ready, staff roles defined, a clear pathway to emergency services — not an improvised response assembled in the moment.

Full guidance for 4.5 →

1. Is there a specific, dedicated space and process ready for a patient who deteriorates while at the clinic? — A real, ready process, not something assembled improvised in the moment.

2. Is emergency equipment genuinely checked and ready, not assumed functional without verification? — Real, verified readiness, not assumed equipment condition.

3. Are staff roles specifically defined for this scenario, with a clear pathway to emergency services? — Specific, practiced role clarity, not general awareness that an emergency plan exists somewhere.

Every specialist referral is actively tracked from the point it's sent through to a documented, completed appointment — not assumed to have happened simply because the referral was made, with no active follow-up to confirm the patient was actually seen.

Full guidance for 5.1 →

1. Is every referral actively tracked from the point it's sent through to a documented, completed appointment? — Real, active tracking to actual completion, not assumed follow-through.

2. Is there a specific process for identifying a referral that hasn't resulted in a completed appointment within an expected timeframe? — A real, active identification process, not passive hope the referral was completed.

3. When an incomplete referral is identified, is there a genuine follow-up action, not just awareness the gap exists? — Real, active follow-up, not a gap noted without resolution.

Specialist consultation notes and findings are returned to the referring clinician within a specific, defined timeframe, actively confirmed as received — not left to arrive whenever they happen to, or lost entirely in an unreviewed pile of incoming correspondence.

Full guidance for 5.2 →

1. Are specialist findings returned to the referring clinician within a specific, defined timeframe? — A real, specific timeframe, not an open-ended expectation of eventual return.

2. Is receipt of specialist findings actively confirmed, not assumed if nothing seems to go wrong? — Genuine, active confirmation, not passive assumption of receipt.

3. Is there a specific process for following up when specialist findings don't arrive within the expected timeframe? — A real, active follow-up process, not findings simply waited for indefinitely.

At every stage of the referral process, one specific person or role is explicitly responsible for the next step — not left as shared or assumed responsibility that, in practice, no one specifically owns.

Full guidance for 5.3 →

1. Is one specific person or role explicitly responsible for each stage of the referral process? — Real, specific, named responsibility, not shared or assumed ownership.

2. Can any staff member correctly identify who is responsible for a specific stage, without hesitation? — Genuine, confident, consistent knowledge, not uncertainty about who owns a given step.

3. When responsibility changes — staff turnover, role changes — is the assignment genuinely updated, not left stale? — Real, maintained assignment, not an outdated structure that no longer reflects who actually does the work.

A referral for a genuinely urgent clinical concern is tracked and followed up with meaningfully greater urgency than a routine referral — not placed into the same tracking process and timeframe as any other referral, regardless of the underlying concern's real clinical significance.

Full guidance for 5.4 →

1. Is a genuinely urgent referral tracked with meaningfully greater urgency than a routine one? — A real, differentiated process, not identical tracking regardless of clinical significance.

2. Is urgency specifically communicated to the receiving specialist, not left for them to infer? — Explicit, clear urgency communication, not an assumption the specialist will recognise it independently.

3. Is there a specific, shorter timeframe for identifying an incomplete urgent referral, distinct from routine referrals? — A genuinely shorter, specific timeframe, not the same interval applied to every referral.

The patient receives genuine, active support navigating the referral process — clear information about what to expect, help scheduling where needed, someone to contact with questions — not handed a referral and left entirely responsible for making it happen themselves.

Full guidance for 5.5 →

1. Does the patient receive genuine, active support navigating the referral process, not just a referral handed over? — Real, active support, not the patient left entirely responsible for making the referral happen.

2. Is there a specific person the patient can contact with questions or difficulties during the referral process? — A real, known contact, not an assumption the patient will figure out who to ask.

3. Is there genuine follow-up with the patient if an initial specialist contact attempt doesn't result in scheduling? — Real, active follow-up at exactly the most common failure point, not the process ending after one attempt.

Every diagnostic test result is tracked not just to confirmed receipt by the clinician, but to actual, documented action taken in response — not assumed adequately handled simply because someone acknowledged seeing it.

Full guidance for 6.1 →

1. Is every test result tracked to actual, documented action, not only confirmed receipt by the clinician? — Genuine tracking of real action taken, not just acknowledgement of having seen the result.

2. Is there a specific process for identifying a result that was received but never actually acted upon? — A real, active identification process, not an assumption that receipt implies action.

3. Does the patient learn the actual result and its meaning, not just that a test was performed? — Genuine, meaningful communication of the actual finding, not a passive assumption the patient will ask.

History-taking and physical examination genuinely follow a structured, complete approach appropriate to the presenting concern — not abbreviated under time pressure in ways that consistently drive real diagnostic error.

Full guidance for 6.2 →

1. Does history-taking genuinely follow a structured, complete approach, not abbreviated under time pressure? — Real, structured completeness, not a shortcut taken to save time.

2. Does physical examination genuinely match what the presenting concern actually warrants, not a token, minimal check? — Genuine, appropriate examination depth, not a cursory check regardless of the actual concern.

3. Is there a specific process supporting complete data gathering even during high-volume, time-pressured periods? — A real, defined support process, not an assumption that thoroughness will hold up under pressure without help.

Prescribing, dispensing, and ongoing monitoring of medications follow specific, defined safety processes — genuine allergy and interaction checking, clear instructions, monitoring where clinically required — not left to individual clinician memory and informal practice alone.

Full guidance for 6.3 →

1. Does prescribing follow a defined process for genuine allergy and interaction checking, not reliance on memory alone? — A real, systematic check, not individual clinician memory as the only safeguard.

2. Do patients receive clear, understandable instructions for new or changed medications, verified as understood? — Genuine, verified understanding, not instructions given without confirmation.

3. Is monitoring genuinely scheduled and tracked for medications that clinically require it, not left to chance? — Real, scheduled, tracked monitoring, not an assumption it will happen without a defined process.

Point-of-care diagnostic testing performed at the clinic is verified as genuinely accurate against a recognised quality standard — regular calibration, quality control checks — not simply assumed reliable because the device is in use and produces a result.

Full guidance for 6.4 →

1. Is point-of-care testing genuinely verified as accurate against a recognised quality standard, not assumed reliable? — Real, verified accuracy, not an assumption based on the device simply producing a result.

2. Are regular calibration and quality control checks genuinely performed and documented? — Real, scheduled, documented checks, not skipped or assumed unnecessary.

3. Is there a specific process for what happens if a quality control check fails? — A real, defined response, not testing continuing regardless of a failed check.

The physical clinical environment — equipment maintenance, infection control supplies, adequate space for examination and privacy — genuinely supports safe patient care, not simply meets a documentation checklist while real, everyday practice tells a different story.

Full guidance for 6.5 →

1. Does equipment maintenance genuinely reflect real, current condition, not just a completed checklist? — Real, verified equipment condition, not documentation completed without genuine follow-through.

2. Are infection control supplies genuinely, consistently available at the point of use, not just stocked somewhere in the building? — Real, practical availability where actually needed, not theoretical stock elsewhere.

3. Does examination space genuinely support patient privacy and dignity, not just meet a minimal documented standard? — Real, practical privacy in daily use, not a standard met only on paper.

A genuine, defined coverage arrangement exists for when the practice's own doctor is unavailable — illness, leave, emergency — with a real, named alternative for patients needing care in that gap, not an assumption that patients will simply wait or seek care elsewhere on their own.

Full guidance for 7.1 →

1. Does a genuine, defined coverage arrangement exist for when the doctor is unavailable? — A real, specific arrangement, not an assumption that patients will manage without care.

2. Is there a real, named alternative provider or facility patients can be directed to during a coverage gap? — A specific, real alternative, not a vague suggestion to seek care elsewhere.

3. Are patients genuinely informed of the coverage plan, not left to discover it only when they need it? — Real, proactive patient awareness, not information they only encounter during an actual gap.

The physician's own wellbeing and burnout risk is genuinely, actively monitored and supported — real access to support, genuine attention to sustainable workload — not treated as a private matter left entirely to individual resilience with no structural attention at all.

Full guidance for 7.2 →

1. Is physician wellbeing genuinely, actively monitored, not treated as a purely private matter? — Real, active attention, not an assumption that wellbeing is solely the individual's own concern.

2. Does the physician have genuine, real access to support if burnout risk is identified? — Actual, accessible support, not a theoretical resource that's difficult to genuinely use.

3. Is workload genuinely, periodically reviewed for sustainability, not assumed manageable indefinitely? — Real, periodic review, not an assumption the current pace is sustainable without ever checking.

The practice maintains a genuine, ongoing quality improvement process — even a small, single, well-chosen project — not the absence of any structured improvement effort simply because the practice is too small for a formal committee structure. The practice has a named clinician with documented accountability for clinical and financial decisions, and a brief, genuine statement of mission, values, and expected conduct — scaled to practice size, not absent because the practice is small.

Full guidance for 7.3 →

1. Does the practice maintain a genuine, ongoing quality improvement effort, even at small scale? — A real, specific improvement effort, not the absence of one justified by practice size.

2. Is the improvement effort based on a real, identified gap specific to this practice, not a generic exercise? — Genuine, specific relevance to this practice's actual circumstances, not a generic template.

3. Is there real evidence the improvement effort has produced a genuine, measurable change? — Actual, measurable outcome, not activity without demonstrated real effect.

4. Is there a named person with documented accountability for clinical decisions and a separate, documented accountability for financial decisions, even where the same individual holds both roles? — Named, documented accountability for each, even at a one-doctor practice, not an informal assumption that the owner handles everything.

5. Does the practice have a brief, genuine written statement of its mission, values, and expected conduct, scaled appropriately to its size? — A real, if brief, statement specific to this practice, not an absence of one on the assumption that a small practice doesn't need it.

6. Is every policy and procedure in use authorised by a named person and reviewed on a defined schedule to confirm it's still current? — A real, if lightweight, authorisation and review process, scaled to practice size, not absent entirely.

Every staff member, however few the practice employs, receives genuine, documented training specific to their actual role — not informal, on-the-job learning alone with no structured content or verification of competency. The clinician's own licence or qualification is verified directly with the issuing body, both at the start of practice and on renewal, and performance and competency are genuinely evaluated on a defined schedule, not simply assumed from tenure.

Full guidance for 7.4 →

1. Does every staff member receive genuine, documented training specific to their actual role? — Real, structured training with documentation, not informal on-the-job learning alone.

2. Is competency genuinely verified, not simply assumed from time spent in the role? — Real, active verification, not an assumption that tenure alone confirms competency.

3. Is training genuinely refreshed periodically, not completed once and never revisited? — Real, ongoing training, not a single initial session treated as sufficient indefinitely.

4. Is the clinician's own licence verified directly with the issuing body, both initially and on renewal, not taken on their word alone? — Direct verification, even for the practice's own owner-clinician, not an assumption that ownership implies current licensure.

5. Is performance and competency genuinely evaluated on a defined schedule, documented, not simply assumed from years in practice? — A real, periodic, documented evaluation, even at a small practice, not an absence of one because the clinician is also the owner.

When something goes wrong or nearly goes wrong, the practice genuinely reviews what happened and why, with real, documented change resulting where warranted — not an incident logged and filed without any real reflection or resulting action.

Full guidance for 7.5 →

1. When something goes wrong or nearly does, is there genuine review of what happened and why? — Real, active reflection, not an incident simply logged and filed.

2. Does this review result in genuine, documented change where warranted, not review without action? — Real, resulting change, not reflection that doesn't translate into any actual adjustment.

3. Are near-misses genuinely reviewed with the same seriousness as actual incidents, not dismissed because no harm occurred? — Genuine attention to near-misses, not only events that actually resulted in harm.

Care is genuinely adapted to a patient's migration and displacement experience — including trauma-informed practice, awareness of legal-status barriers to access, and support for continuity of care — not delivered identically regardless of that history.

Full guidance for 8.1 →

1. Is care genuinely adapted to a patient's migration and displacement experience, not delivered identically regardless of history? — Genuine adaptation, not a generic cultural-awareness statement.

2. Is trauma-informed practice genuinely applied, not just referenced as a principle? — Actual practice adaptation, not an assumption of general sensitivity.

3. Are staff aware of legal-status barriers to access that may affect this specific patient? — Specific awareness, not a general sense that barriers can exist.

Patients are supported to genuinely understand both their own care and how to navigate the wider health system — with understanding actively verified through methods like teach-back, in plain language, not assumed from silence, a nod, or general goodwill information about the system.

Full guidance for 8.2 →

1. Is understanding actively checked using teach-back, for both the care plan and how the system works? — Asking the patient to explain back in their own words, not just "do you understand?"

2. Is practical guidance given on navigating the wider system, including registering elsewhere if they relocate? — Real navigation guidance beyond this one clinic, not general encouragement.

3. Is information communicated in plain language, particularly when working through an interpreter? — Complex terminology strains interpretation and comprehension together.

Trained interpreters or cultural mediators are engaged for language-discordant consultations — never minor children, and only family members when genuinely no other option exists and the situation is not high-risk.

Full guidance for 8.3 →

1. Are trained interpreters or cultural mediators engaged for language-discordant consultations? — Not ad hoc bilingual staff or family members as the default.

2. Is a minor ever used to facilitate interpretation for a family member? — This should never happen — a specific, absolute rule, not a judgement call.

3. When a family member interprets due to genuine unavailability of a trained interpreter, is this reserved for low-risk situations only? — Not used for informed consent, complex diagnoses, or bad news — situations WHO specifically flags as requiring professional language support.

The practice actively engages with legal, social, and community support services relevant to refugee and migrant patients, and conducts effective handover of care that includes migration- and displacement-related context — not treating primary care as isolated from these interconnected factors.

Full guidance for 8.4 →

1. Does the practice actively engage with relevant social support services, not treat health care in isolation? — Genuine, active engagement, not a general awareness that such services exist.

2. Does handover to another provider specifically include migration- and displacement-related context? — Specific inclusion of this context, not a generic clinical handover.

3. Are staff aware of specific local services relevant to this population, not just services generally? — Specific, current knowledge, not a vague sense that support services exist somewhere.

Every newly registered refugee or migrant patient receives a comprehensive initial health assessment screening for the documented triple burden — infectious disease, non-communicable disease, and mental health — not a narrow, single-issue check that misses the other two dimensions of this well-established pattern.

Full guidance for 8.5 →

1. Does every newly registered refugee or migrant patient receive a comprehensive initial health assessment? — A real, comprehensive assessment, not a narrow check limited to one presenting concern.

2. Does this assessment genuinely cover all three dimensions of the triple burden — infectious disease, non-communicable disease, and mental health? — Genuine coverage of all three, not one or two dimensions while the others go unaddressed.

3. Does the assessment include catch-up vaccination review, not assumed current without checking? — Real, active vaccination status review, not assumed adequacy.

Staff use evidence-informed guidelines specific to refugee and migrant health where they exist, recognise where the health needs of this population differ from the general population, and identify where evidence gaps remain — not applying general primary care guidelines uncritically to a population with documented, different health needs.

Full guidance for 8.6 →

1. Are staff aware of evidence-informed guidelines specific to refugee and migrant health where they exist? — Specific, current awareness, not general clinical knowledge assumed to be sufficient.

2. Do staff recognise where this population's health needs genuinely differ from the general population? — Genuine, specific recognition, not an assumption that general guidelines always apply equally.

3. Is practice adapted where population-specific evidence indicates a different approach is warranted? — Actual practice adaptation, not awareness without application.

Staff maintain active awareness of their own culture, beliefs, and potential biases through structured reflective practice, and the practice actively fosters a supportive environment with genuine access to psychological support — not assumed self-awareness or an assumption that staff will manage vicarious trauma exposure on their own.

Full guidance for 8.7 →

1. Does the practice have a structured process for staff reflective practice regarding bias and cultural awareness? — A defined process, not an assumption that staff will naturally self-reflect adequately.

2. Does the practice provide genuine, accessible psychological support and a real space to discuss difficult cases? — Actual, used support and a real, regular opportunity, not a theoretical benefit or informal hope.

3. Can staff describe a specific instance of adapting their practice after recognising a bias, and do they recognise signs of vicarious trauma in themselves? — Genuine, concrete examples, not general statements of good intentions or awareness.

When a refugee or migrant patient relocates, the practice actively supports genuine continuity of their care — a portable, patient-held summary, active handover where a new provider is known — not treating relocation as an automatic, unavoidable end to any continuity at all.

Full guidance for 8.8 →

1. Does the practice actively support continuity when a patient relocates, not treat relocation as an automatic end to continuity? — Real, active support, not passive acceptance that continuity simply ends.

2. Is a portable, patient-held summary genuinely provided, giving the patient something to carry forward? — A real, usable summary the patient actually holds, not information that stays only in this practice's own records.

3. Where a new provider is known, is active handover genuinely attempted, not assumed impossible? — A real, attempted handover, not an assumption that contact with a future provider isn't achievable.

The practice can name which legal status categories it actually serves — asylum seeker, recognised refugee, stateless person, and others — and demonstrates it doesn't apply a single, uniform assumption about access rights across all of them.

Full guidance for 8.9 →

1. Can staff name the specific legal status categories this practice actually serves? — Specific, named categories, not a general sense that "migrants" are served.

2. Does the practice avoid applying a single, uniform assumption about access rights across all statuses? — Genuine differentiation, not treating all categories identically.

3. Is there a specific process for verifying which category applies when it's genuinely unclear? — A real, defined process, not guesswork or assumption when status is ambiguous.

Care is provided and fully documented for every patient regardless of immigration or legal status, with no differential standard of care, documentation practice, or record-keeping applied based on status — not a lesser or informal standard applied to patients without documented status.

Full guidance for 8.10 →

1. Is the same standard of care applied and documented the same way regardless of a patient's immigration or legal status? — Genuinely equal treatment, not a lesser or informal standard for undocumented patients.

2. Are staff specifically trained that immigration status is never a reason to withhold or alter care or documentation? — Specific, documented training, not assumed understanding.

3. Is patient information protected with the same confidentiality standard regardless of status, with no informal sharing of status-related information? — The same confidentiality protection extended to every patient, without exception.

The clinic genuinely assesses its environmental impact — energy, water, waste — proportionate to its role as a community-facing primary care facility, not assumed unnecessary given its typically modest scale.

Full guidance for 9.1 →

1. Has the clinic genuinely assessed its environmental impact, not assumed its scale makes this unnecessary? — A real, documented assessment, proportionate to the clinic’s actual size.

2. Does this genuinely cover energy, waste, and water? — Real, multi-dimensional coverage, not one easy metric standing in for the whole picture.

3. Is the assessment genuinely revisited periodically? — Real, periodic review, not a static assessment assumed to remain valid.

Clinical and hazardous waste is genuinely segregated from general waste at the point of generation and disposed of through a responsible, verified pathway — not a waste stream mixed for convenience given the clinic’s typically lower volume.

Full guidance for 9.2 →

1. Is clinical waste genuinely segregated at every point of generation? — Real, consistent segregation.

2. Is the disposal pathway genuinely verified? — A real, verified pathway, not an assumption resting on a vendor’s claims.

3. Are staff genuinely trained with real, observable compliance? — Real, demonstrated staff practice.

Procurement decisions genuinely factor in environmental impact alongside cost and patient need — including vaccine and supply packaging common to high-volume primary care delivery — not sustainability treated as an afterthought with purchasing decided purely on price.

Full guidance for 9.3 →

1. Does procurement genuinely weigh environmental impact? — Real, documented consideration.

2. Is there a real, documented instance of a procurement choice genuinely influenced by environmental considerations? — A concrete, real example.

3. Are high-volume consumables — vaccine supplies, dressings — genuinely reviewed for lower-impact alternatives? — A real, ongoing review of the clinic’s actual high-volume purchases.

The clinic genuinely monitors its energy and resource consumption, pursuing real, achievable reductions appropriate to its scale and the communities it serves — not resource use left untracked because the facility is small.

Full guidance for 9.4 →

1. Is energy consumption genuinely tracked? — Real, ongoing tracking.

2. Has the clinic genuinely identified and pursued at least one real efficiency improvement? — A real, concrete improvement.

3. Is progress genuinely reviewed periodically? — Real, periodic review.

Staff genuinely understand and participate in the clinic's sustainability practices, and this understanding genuinely extends to the health-promotion and community-education role primary care clinics often play — not a sustainability policy known only to management.

Full guidance for 9.5 →

1. Can staff asked directly describe at least one genuine sustainability practice? — Real, demonstrated staff awareness.

2. Are patients genuinely made aware of relevant initiatives where appropriate? — Real, visible communication.

3. Is staff input genuinely sought and considered? — Real, two-way engagement.

The clinic genuinely considers climate-related risks to its own continuity of operation and, specifically, to the continuity of essential preventive services — vaccination programmes, maternal health visits — that communities genuinely depend on this clinic to deliver reliably.

Full guidance for 9.6 →

1. Has the clinic genuinely identified its specific climate-related operational risks? — A real, specific risk identification.

2. Is there a real, workable response plan, including continuity of essential preventive services? — A genuine, usable plan covering the clinic’s real population-health role.

3. Is this plan genuinely reviewed and tested? — Real, periodic review and testing.

The clinic's sustainability goals and practices are genuinely reviewed and updated as circumstances change — not a document written once and never genuinely examined for whether it still reflects the clinic's actual practice.

Full guidance for 9.7 →

1. Are sustainability goals genuinely reviewed on a real, defined schedule? — A real, periodic review.

2. Is there a real, documented instance of a goal genuinely being revised? — A concrete, real example.

3. Is responsibility for this review genuinely assigned to a specific person or role? — A real, named accountability.

Before adopting any new digital system — patient records, vaccination tracking, appointment reminders — the clinic genuinely evaluates its cost, benefit, and compatibility with existing systems, not adopted on vendor assurance with no real internal evaluation.

Full guidance for 10.1 →

1. Is a genuine cost/benefit evaluation conducted before adoption? — A real, documented evaluation.

2. Is compatibility with existing systems genuinely checked? — Real, verified compatibility.

3. Are potential unintended consequences genuinely considered before go-live? — Real, proactive consideration.

A genuine process ensures that patients who cannot use digital devices, lack internet access, or face language or literacy barriers are never disadvantaged in booking, reminders, or health communication — a genuinely heightened risk in primary care settings that often serve lower-income, migrant, or less digitally connected populations.

Full guidance for 10.2 →

1. Is there a genuine, equally functional alternative for patients who cannot use a digital channel? — A real, equivalent alternative.

2. Was a new digital service genuinely pre-tested with representatives of the clinic's actual patient population, including those with language or literacy barriers? — Real, prior testing with the genuinely affected community.

3. Is there real evidence a patient using the alternative route received equivalent service? — A real, demonstrated instance.

The clinic has genuine access to technical support — in-house, vendor-provided, or contracted — for its digital systems, with testing before full implementation, not systems left running with no real support behind them.

Full guidance for 10.3 →

1. Does the clinic have genuine, accessible technical support? — Real, available support.

2. Were genuine testing and quality checks performed before implementation? — A real pre-launch check.

3. Is there a real, known route to support when an issue arises? — A genuine, known escalation path.

Any artificial intelligence tool used to support screening, triage, or risk stratification is introduced in accordance with applicable law, or where none exists, with available best-practice guidance such as WHO's AI ethics and governance guidance — not adopted with no reference to any external standard of responsible use.

Full guidance for 10.4 →

1. Is any AI system genuinely introduced in line with applicable law? — Real, verified compliance.

2. Where no law exists, is introduction genuinely informed by recognized guidance? — A real, referenced source.

3. Can the clinic identify, when asked, the specific basis for AI governance? — A real, specific answer.

The clinic genuinely monitors any AI-assisted screening or risk tool for over-diagnosis, missed diagnosis, and specifically for differential accuracy across the clinic's actual patient population — a genuine, documented risk where AI tools trained on unrepresentative data can perform less reliably for exactly the populations primary care most often serves.

Full guidance for 10.5 →

1. Is AI-assisted output genuinely audited for accuracy? — Real, ongoing audit.

2. Is accuracy genuinely checked for consistency across the clinic's actual patient population, not assumed uniform? — A real, specific equity check given documented risks of AI performance bias.

3. Is there a documented instance of monitoring identifying a genuine issue, with a real response? — A real, concrete example.

Clinical staff who will actually use a new AI tool are genuinely consulted before its introduction, with real training needs identified and addressed — not a tool rolled out with no engagement beyond a brief notification.

Full guidance for 10.6 →

1. Are staff genuinely consulted before a new AI system's introduction? — Real, prior consultation.

2. Does consultation genuinely identify training needs, actually addressed? — Real needs matched by real training.

3. Can staff asked directly describe having been genuinely consulted? — Tests whether consultation actually reached staff.

The clinic has genuinely considered and documented accountability for care decisions made with AI support — who is responsible when an AI-assisted decision is wrong — not leaving this as an unexamined question until it actually matters.

Full guidance for 10.7 →

1. Is clinical accountability for an AI-supported decision explicitly documented? — A real, clear answer.

2. Do clinicians genuinely understand their own accountability for the final decision? — Real, demonstrated understanding.

3. Is there a defined process for reviewing accountability in a safety incident? — A real, usable process.

A patient whose care involves an aspect delivered with AI system support is genuinely informed of this — not left to assume every decision was made by a human clinician alone, with disclosure treated as optional rather than a genuine, standard part of informed care.

Full guidance for 10.8 →

1. Is a patient genuinely informed when an aspect of their care involves AI system support? — Real, standard disclosure, not an assumption that the patient will simply figure it out or doesn’t need to know.

2. Is this disclosure genuinely understandable, not buried in technical language or a general consent form a patient never actually reads? — A real, plain-language explanation a patient could genuinely act on.

3. Can a patient asked directly confirm they were genuinely told AI was involved in an aspect of their care? — A real, concrete confirmation, not disclosure that exists in policy but never genuinely reaches the patient.

Every member of the clinic's workforce — employed clinicians, community health workers, visiting specialists, and volunteers alike — has genuine assurance of the qualifications and scope of practice their role requires, including community health workers whose training and scope are often genuinely distinct from licensed clinical staff.

Full guidance for 11.1 →

1. Does genuine credential or competency assurance extend to community health workers, not licensed clinicians alone? — Real, consistent coverage appropriate to each role’s genuinely distinct training basis.

2. Is each person's actual scope of practice genuinely verified and genuinely respected in daily practice? — A specific, documented match, including real limits on what a community health worker does independently.

3. Is there a real, defined process if someone practises outside their verified scope? — A genuine corrective process.

The continued competency of every workforce member is genuinely, regularly evaluated against their actual job description and scope, including the genuinely distinct competencies required of community-facing and preventive care roles.

Full guidance for 11.2 →

1. Is ongoing competency genuinely evaluated on a real, defined schedule? — A real, periodic evaluation.

2. Does evaluation genuinely cover the person's actual current duties? — A specific, role-relevant evaluation.

3. When a genuine performance gap is identified, is there a real, defined response? — A genuine corrective process.

Every workforce member has genuine access to ongoing education — including public health and preventive care updates genuinely relevant to a primary care setting's population-health role — not education treated as a one-time induction event.

Full guidance for 11.3 →

1. Does every workforce member have genuine, ongoing access to education? — Real, continuing access.

2. Are genuine development opportunities offered in preventive and population health, not only compliance training? — Real development opportunities relevant to this setting's genuine role.

3. Can staff asked directly describe a genuine education opportunity taken in the past year? — A real, specific example.

The clinic genuinely protects the health and safety of its workforce — required vaccinations, personal protective equipment, prevention of needlestick injuries — including community health workers conducting outreach visits outside the clinic itself, who face genuinely distinct safety considerations.

Full guidance for 11.4 →

1. Is PPE genuinely available and used? — Real, observed use.

2. Are genuine, specific measures in place for outreach or community-visit safety, where this is part of the role? — Real, specific measures appropriate to field-based work.

3. Are required staff vaccinations genuinely tracked and current? — Real, verified tracking.

A genuine process exists for investigating and resolving workplace issues raised by staff — including whistleblowing concerns — with real protection from adverse treatment, not a grievance process that exists on paper with no real follow-through.

Full guidance for 11.5 →

1. Is there a genuine, accessible process for staff to raise workplace issues? — A real, known process.

2. Is there real, documented evidence that raised issues lead to genuine resolution? — Genuine follow-through.

3. Are staff who raise concerns genuinely protected from adverse treatment? — Real, demonstrated protection.

The clinic takes genuine, concrete steps to protect staff from aggression — including the genuinely distinct risks faced by community health workers conducting home or outreach visits, who often work without the physical safety infrastructure of a clinic setting.

Full guidance for 11.6 →

1. Are genuine, specific measures in place, including for outreach and home-visit staff? — Real, specific measures appropriate to this setting’s distinct, field-based risk profile.

2. Are incidents of aggression genuinely tracked and reviewed? — Real, systematic tracking.

3. Can staff describe a real, specific instance where a protective measure genuinely worked? — A real, concrete example.

The clinic has a genuine, systematic approach to gathering staff feedback — including community health workers whose field-based role can easily leave them disconnected from clinic-based feedback processes — with real analysis and a genuine, implemented response.

Full guidance for 11.7 →

1. Is feedback genuinely gathered from field-based staff, not only those physically present in the clinic? — Real, ongoing collection reaching staff genuinely at risk of being overlooked.

2. Is collected feedback genuinely analysed for trends? — A real, documented analysis process.

3. Is there a documented instance where feedback genuinely led to an implemented change? — A real, concrete example.

The clinic genuinely monitors staff sick leave and the real reasons people leave, using this to inform genuine changes supporting workforce wellbeing and retention, not attrition treated as an unexamined, unavoidable cost of doing business.

Full guidance for 11.8 →

1. Is staff sick leave data genuinely monitored and analysed? — Real, ongoing analysis.

2. Are the genuine reasons staff leave actually captured? — Real, specific exit data.

3. Is there a documented instance where this data genuinely informed a real, implemented change? — A real, concrete example.

The organisation genuinely monitors and responds to real patterns of equity across recruitment, work allocation, scheduling, and promotion — not an assumption that fair treatment exists simply because no formal complaint has been raised.

Full guidance for 11.9 →

1. Is workforce data on recruitment, work allocation, scheduling, and promotion genuinely monitored for patterns of inequity? — A real, documented monitoring process, not an assumption that fairness exists by default.

2. Where a genuine pattern is identified, is there a real, defined response? — A genuine corrective process, not data collected with no real follow-through.

3. Is there a real, documented instance of this monitoring genuinely informing a change in practice? — A concrete, real example.