Standards › ASF Health Standards v10 › Standard 1
Standard 1
Foundation: Universal Base
The base standard. Every facility meets it. It covers identification, safety, consent, medicines, staff, records and the patient voice.
Every patient is verified using at least two identifiers before any medication, procedure, blood product or specimen collection, and at every point where contact could go wrong.
Why it matters. Most wrong-patient errors happen when staff rely on a bed or room number, or on a check made earlier in the stay. The safe practice is two identifiers, full name and date of birth, checked with the patient at every contact where a mistake could cause harm.
How the surveyor verifies this criterion
Sample. Emergency department: follow 2 patients from arrival to discharge or transfer, one medicine and one specimen each. Ward: follow 2 inpatients through one medicine round and one specimen collection. Records: the last 20 specimen labels and 10 medication charts per area. Staff: interview 3 people (one doctor, one nurse, one phlebotomist or lab staff).
1. Two identifiers are checked before every medicine.
Method. Observe one full medicine round. For each dose, see the nurse ask the patient for name and date of birth, or read the wristband, then compare with the medication chart.
Evidence to show. Medication chart for the observed doses; close-up photo of the wristband with identifiers masked and no face in frame.
Pass when. Every observed dose has two identifiers checked with the patient. One exception is a finding.
2. Two identifiers are checked before every specimen collection, with the patient present.
Method. Observe 2 specimen collections (one in ED, one on a ward). Check the label is written at the bedside, in front of the patient.
Evidence to show. Photo of the labelled tube with patient identifiers masked; the matching request form.
Pass when. Both collections are labelled at the bedside with two identifiers, date, time and initials.
3. Identification is checked again before blood products and procedures.
Method. Observe 1 blood transfusion or procedure check (ED or theatre). Check the check is repeated at the bedside, not copied from an earlier entry.
Evidence to show. Signed transfusion or procedure checklist for that patient (identifiers masked).
Pass when. A bedside check with two identifiers is written on the checklist at the time of the procedure.
4. Specimen labels are completed at the point of collection, not later.
Method. Review the last 20 specimen labels against the collection log. Check that the time, date and initials match the collection time.
Evidence to show. Log extract of 20 labels with the check recorded on each (identifiers masked).
Pass when. 20 of 20 labels are complete and match the collection time. Any label written away from the patient is a finding.
5. Every inpatient and ED patient wears a wristband that is present and legible.
Method. Walk the ED and one ward. Check the wristband on the 2 patients followed in the sample, plus 8 others at random.
Evidence to show. Photo of the wristband for each sampled patient, identifiers masked.
Pass when. All 10 patients have a legible wristband with name and date of birth. A missing or illegible wristband is a finding.
6. Staff describe the process correctly.
Method. Ask the 3 staff members: ‘How do you confirm who a patient is before giving a medicine or taking a sample?’
Evidence to show. Interview notes (role, answer).
Pass when. Each answer names two identifiers checked with the patient. An answer based on bed, room or the chart alone is a finding.
7. Patients can state their identifiers when asked.
Method. Ask the 2 ED patients and 2 ward patients for their full name and date of birth. If the patient cannot answer, ask a family member and check the wristband.
Evidence to show. Notes of the answer and the wristband check.
Pass when. The patient or the wristband gives the correct full name and date of birth.
Immediate fail (any one means the criterion is not met)
- A room or bed number is used as the only identifier.
- A medicine is given or a specimen is taken without two identifiers checked with the patient.
- A specimen label is written away from the patient.
Documents
E-learning
- Correct Patient Identification (—)
- Patient Identification, Informed Consent and Patient Rights (T-07)
References
- World Health Organization (2007). WHO launches ‘Nine patient safety solutions’, Solution 2: patient identification. Geneva: WHO. https://www.who.int/news/item/02-05-2007-who-launches-nine-patient-safety-solutions
- National Patient Safety Agency (2007). Safer Practice Notice: Standardising wristbands improves safety. London: NPSA. Cited in NHS England, Recommendations from NPSA alerts that remain relevant. https://www.england.nhs.uk/wp-content/uploads/2020/11/Recommendations-from-NPSA-alerts-that-remain-relevant-to-NEs-FINAL.pdf
- International Organization for Standardization (2022). ISO 15189:2022 Medical laboratories: Requirements for quality and competence. Geneva: ISO. Specimen identification requirements apply to the pre-examination process (clause to be confirmed).
Hand hygiene stations are present where care happens, and staff use them. Use is observed, not self-reported.
Why it matters. Hands carry most healthcare-associated infections. A dispenser far from the bed is rarely used, and staff over-report their own hand hygiene. Compliance has to be observed to be known.
What the surveyor checks
- Are hand hygiene stations physically present at the point of care, not only at ward entrances?
- Is compliance measured through unannounced observation, not self-report?
- Is supply available at unannounced checks as well as scheduled ones?
Documents
No documents yet.
E-learning
Informed consent explains risks, benefits and alternatives before every significant procedure. It is a conversation the patient can describe back, not a form signed on the way in.
Why it matters. Consent is a conversation, not a signature. The patient should be able to say, in their own words, what the procedure is, its main risk, and one alternative. A form signed in a corridor before theatre is not consent.
What the surveyor checks
- Can a patient who signed a consent form in the last month describe, in their own words, what the procedure involves?
- Are risks, benefits and at least one alternative recorded as discussed, not only the name of the procedure?
- Is consent taken early enough that the patient could realistically change their mind?
Documents
E-learning
- Patient Identification, Informed Consent and Patient Rights (T-07)
- Healthcare Ethics for ASF Accreditation (A-07)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
Every patient’s risk of falling is assessed on admission and after any change in condition, and measures are in place for patients at risk.
Why it matters. A falls score done once at admission misses patients who become unsteady after surgery, sedation or a new medicine. The measures must be visible at the bed: the call bell in reach, a light on at night, safe footwear.
What the surveyor checks
- Is falls risk assessed on admission and after any change in condition, with the result recorded?
- For patients assessed as at risk, are the measures in place and visible, such as call-bell access, lighting, footwear, supervision or equipment?
- Are falls and near-falls reported and reviewed to change practice?
Documents
E-learning
- Slip, Trip & Fall Prevention (FALL-01)
Planned course: Hospital falls prevention, based on the falls guideline. New course planned.
References
- World Health Organization (2007). WHO Global Report on Falls Prevention in Older Age. Geneva: WHO. Open source (E-008)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
Care is provided without discrimination on grounds of race, religion, sex, gender identity, sexual orientation, disability, nationality, migration status or ability to pay for emergency care. Reasonable adjustments are made for disability.
Why it matters. No one is turned away from emergency care because of payment, nationality or migration status. Access for people with disabilities is a legal duty and a practical one: a step that a wheelchair cannot pass is a barrier to care.
What the surveyor checks
- Is emergency care provided regardless of ability to pay, nationality or migration status?
- Can patients with disabilities enter, be examined and be treated, with reasonable adjustments made?
- Is an interpreter or communication support available on request, and are patients told they can ask for it?
Documents
E-learning
- Equity, Diversity & Inclusion in Healthcare (EDI-001)
- Language Access & Communication Standards (LANG-001)
- Refugee & Migrant Health Standards (REF-001)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
The emergency entrance is marked, lit and kept clear. Fire safety equipment is tested on schedule, and an evacuation drill has been run with staff.
Why it matters. In a fire or emergency, people leave by routes they can see and use. Equipment left in a corridor, a sign that cannot be seen at night, or a drill that was only discussed all fail this test.
What the surveyor checks
- Is the emergency entrance signed from the road and visible at night?
- Are the route from the road and the evacuation routes clear in practice, checked by walking them?
- Is fire safety equipment tested on a defined schedule, and has an evacuation drill been run with staff participation?
Documents
E-learning
- Emergency Preparedness and Fire Safety (T-10)
- Basic Fire Response & Extinguisher Use (FIRE-01)
- Safety & Emergency Preparedness (H-05)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
A patient rights charter is displayed where patients pass, and patients can describe their rights in their own words. The charter names privacy, dignity, confidentiality, personal safety, consent, the right to refuse treatment, and the patient’s cultural and spiritual preferences.
Why it matters. A charter on an office wall protects no one. The test is whether a patient, asked directly, can name one of their rights. The charter must be where patients wait and in the languages they speak.
What the surveyor checks
- Is the charter visibly displayed where patients wait or arrive?
- Is the charter written in plain language, in the languages patients speak?
- Can a patient, asked directly, describe at least one of their rights in their own words?
Documents
E-learning
- Patient Rights and Responsibilities (A-01)
- Patient Identification, Informed Consent and Patient Rights (T-07)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Every clinical staff member’s qualifications are verified directly with the issuing body and rechecked on renewal. Each new clinical staff member receives structured orientation before practising independently. This includes agency staff, volunteers and every other member of the workforce, checked against the scope of practice their role requires.
Why it matters. A licence copy in a file is not verification. The issuing body must confirm it, and the check must be repeated on renewal. Agency staff and volunteers who give care are included.
What the surveyor checks
- Is each clinical staff member’s licence or qualification verified directly with the issuing body?
- Are credentials rechecked on renewal, with a named person responsible for tracking them?
- Does each new clinical staff member complete structured orientation before practising independently?
- Are agency staff, volunteers and other workforce members verified for the scope their role requires?
Documents
E-learning
- Credentialing, Competence and the Training Matrix (T-14)
- Safety Training Programme & Competency Assessment (TRAIN-01)
- Staff Health Screening & Wellness Standards (STAFF-01)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
Prescriptions are complete and legible, high-risk medicines have a defined second check by a trained, designated person, and medicines are stored at the correct temperature and secured.
Why it matters. Most medicine errors happen at prescribing and administration. A high-risk medicine needs a second check by a trained person, and temperature-sensitive medicines need a logged fridge. Controlled medicines must match the count.
What the surveyor checks
- Are prescriptions legible and complete, including dose, route and frequency?
- Is there a defined second check for high-risk medicines?
- Are prescribing and administration errors recorded and reviewed, not only corrected?
- Are medicines stored at the correct temperature, with checks recorded, and controlled medicines secured and counted?
Documents
E-learning
- Medication Safety: Operating SOP-MED-01 End to End (T-08)
- Care & Treatment: Clinical Standards for Accreditation (H-04)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
Sharps containers are at the point of use, never overfilled, and clinical waste is segregated correctly at disposal.
Why it matters. Sharps injuries and waste exposure are common and avoidable. Containers at the point of use and correct segregation at the bin prevent most of them. A container that is overfilled is a hazard.
What the surveyor checks
- Are sharps containers available at the point of use, so no one carries an exposed sharp any distance?
- Are containers replaced before they reach unsafe fill levels?
- Is clinical waste segregated correctly at the point of disposal?
Documents
E-learning
No course linked yet.
Planned course: Sharps and clinical waste. New course planned.
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
Records contain all mandatory elements and are audited. Patient information is kept private in practice. Incidents and complaints are reported, reviewed and answered, and changes are recorded when they lead to one.
Why it matters. A record that is incomplete cannot show what happened. An incident with no review repeats. The test is whether the organisation changes practice after an event, and records that change.
What the surveyor checks
- Are records audited for completeness against a defined list of mandatory elements?
- Are screens and clinical conversations arranged so that patient information cannot be seen or overheard?
- Are incidents and complaints reviewed, answered, and linked to a recorded change in practice where one is needed?
Documents
E-learning
- Incident Reporting, Just Culture and Open Disclosure (T-09)
- Records, Confidentiality and Data Protection (T-11)
- Complaints Handling and Patient Feedback (T-12)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
- World Health Organization (2007). Nine patient safety solutions, including correct patient identification. Geneva: WHO. Open source (E-007)
Patients are offered real choices and taught what they need to manage their own care. Their preferences and decisions are recorded. Patients and carers take part in improving the service through a patient council that has written terms of reference and whose advice is recorded with the facility’s response.
Why it matters. Patients make better decisions when they understand their options. A patient council that gives advice which is never answered is not influence. The advice and the facility’s response must both be recorded.
What the surveyor checks
- Are the options, including doing nothing where appropriate, explained, and is the agreed decision recorded with the patient’s preferences?
- Is each patient who must manage their own care taught the key steps, and asked to explain them back?
- Does the facility have a patient council with written terms of reference, and is each piece of its advice recorded with the facility’s response?
Documents
E-learning
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
The organisation declares, in writing, the setting it is accredited under and every service it provides under that setting, including the transport modes, routes and countries where a transfer service is provided, and the age groups served. The declaration is published to patients and the public and is reviewed at least once a year. A service that is not declared is not provided under the accreditation.
Why it matters. An accreditation decision applies only to the services declared. A service delivered but not declared is a finding, and a transfer service must list its modes, routes and countries.
What the surveyor checks
- Is the declared setting and service list written, including modes, routes and countries for any transfer service?
- Is the declaration reviewed at least once a year, with the review recorded?
- Can the organisation show that every service it delivers appears in its declaration, and that no undeclared service is delivered?
Documents
E-learning
No course linked yet.
Planned course: Declaring the service scope. New course planned.
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
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