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International Accreditation of Healthcare Facilities

Standards › ASF Health Standards v10 › Standard 45

Standard 45

Reception, Waiting and Health Information

Reception, waiting and health information: waiting times measured and shared, urgent patients reassessed while they wait, waiting patients kept informed, plain-language information, and questions answered with teach-back..

5
criteria
9
documents
1
e-learning courses
5
references

Criteria on this page

45.145.245.345.445.5

How to read the colours
Red: Must. Required in every setting. Criteria that protect life are always red.
Green: Medium. Required, adapted to what a transition setting can realistically do.
Yellow: Minimum. The lowest acceptable level in a humanitarian setting, where resources are very limited.

Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.

Reference, not a requirement. Every policy, SOP, form and course on this page is a draft to help you. Adapt it to your hospital, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
45.1Waiting Times Are Measured and SharedHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Waiting times are measured from arrival or booking, compared with a target set by the service, and shared with patients and staff.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

Why it matters. Patients who wait a long time for a service may leave, or be harmed by delay. Measuring the wait and sharing it against a target shows where action is needed.

How the surveyor verifies this criterion

Sample. Review waiting time records for every service with a queue for the last 3 months, and the sharing record.

1. Waiting times are measured from arrival or booking, at the point set for each service.

Method. Compare the measurement points in the policy with the times recorded for a sample of visits.

Evidence to show. Waiting time measurement and sharing (WTG-POL-001).

Pass when. Every sampled wait has a start and an end time, measured at the set point.

2. Each service has a target waiting time, and waits are compared with it each month.

Method. Check the target for each service and the monthly comparison record.

Evidence to show. Waiting time review record (WTG-FRM-001).

Pass when. Every service has a set target and a monthly comparison is recorded.

3. Waiting times are shared with patients and staff.

Method. Check the published or posted waiting times and the staff review record for the sample period.

Evidence to show. Waiting time review record (WTG-FRM-001).

Pass when. Waiting times are shared with patients and reviewed with staff each month.

Immediate fail (any one means the criterion is not met). A clinic records no waiting times for two years, and patients wait over three hours with no one aware of the average.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Maintains the Waiting time measurement and sharing (WTG-POL-001); waiting time register Medium
Nurse (ISCO 2221) Completes the Waiting time review record (WTG-FRM-001); queue and wait-time management Medium

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
WTG-FRM-001 · Waiting time review record Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)
WTG-POL-001 · Waiting time measurement and sharing Chief executive (ISCO 1120) Governing body members N/A Chief executive (ISCO 1120) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Reception & Information: The First Ten Minutes (H-02) Manager; Nurse

References

  1. World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705 Used for: https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
45.2Patients in Urgent Need Are Not Left UnseenHumanitarian settings: MustTransition and fragile: MustStandard: Must

Patients are assessed on arrival for urgency. Those whose condition may change while they wait are reassessed at set intervals and when their condition changes.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. A patient whose condition may change while they wait can deteriorate unseen. Assessing urgency on arrival and checking those patients keeps them from being left.

How the surveyor verifies this criterion

Sample. Review triage and re-check records for every patient who waited in the sample period, including any whose condition changed while waiting.

Immediate fail (any one means the criterion is not met). A child with breathing difficulty waits 90 minutes with no reassessment and is found collapsed in the waiting room.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Checks the criterion at each review Must

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
WTG-SOP-003 · WTG-SOP-003 Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)
WTG-FRM-002 · Waiting patient update record Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Reception & Information: The First Ten Minutes (H-02) Manager; Nurse

References

  1. WHO (2021). Emergency Triage Assessment and Treatment (ETAT): Manual for Participants. Used for: Emergency triage ensures urgent children are seen first. Child-specific, not adult reception. https://news.gmj.ge/guideline/emergency-triage-assessment-and-treatment-etat-manual-for-participants/
45.3Waiting Patients Are Kept InformedHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Patients who wait are told the reason for the wait, given an updated estimate where it changes, and told what to do if they need help.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

Why it matters. Waiting is hard, and it is harder when no one says why. Telling patients the reason for the wait and giving an updated estimate keeps them calm and informed.

How the surveyor verifies this criterion

Sample. Review how waiting patients were kept informed over the sample period, including waits longer than the target.

1. Patients who wait are told the reason for the wait on arrival.

Method. Observe reception on several days and check the script and sign used.

Evidence to show. Keeping waiting patients informed (WTG-SOP-001).

Pass when. Every sampled waiting patient is told the reason for the wait.

2. An updated estimate is given where the wait changes.

Method. Check the update record for each wait that went over its estimate.

Evidence to show. Waiting patient update record (WTG-FRM-002).

Pass when. Every sampled change in the estimate was given to the patient.

3. Patients are told what to do if they need help while waiting.

Method. Check the waiting area signs and the record of the help instruction.

Evidence to show. Waiting patient update record (WTG-FRM-002).

Pass when. Every waiting area displays the help instruction, and each sampled patient was given it.

Immediate fail (any one means the criterion is not met). A patient waits three hours, is given no reason or estimate, and leaves without being seen.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Maintains the Keeping waiting patients informed Medium
Nurse (ISCO 2221) Completes the Waiting patient update record Medium

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
WTG-SOP-001 · Keeping waiting patients informed Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)
WTG-FRM-002 · Waiting patient update record Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Reception & Information: The First Ten Minutes (H-02) Manager; Nurse

References

45.4Health Information Is in Plain LanguageHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Written information is written in plain language, tested with the people who will use it, and available in the languages the population uses.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

Why it matters. Health information that is hard to understand does not help. Writing in plain language, and testing it with the people who will use it, makes it usable.

How the surveyor verifies this criterion

Sample. Review all written health information issued in the last 12 months, and the test record for each item.

1. Written information is written in plain language.

Method. Check each leaflet and sign against the plain-language standard.

Evidence to show. Writing plain-language health information (WTG-SOP-002).

Pass when. Every item meets the plain-language standard.

2. Written information is tested with the people who will use it before it is issued.

Method. Check the test record for each item issued.

Evidence to show. Patient information test register (WTG-REG-001).

Pass when. Every item issued has a recorded test with people who will use it, completed before issue.

Immediate fail (any one means the criterion is not met). A leaflet on medicine doses is written in technical language in one language only, and families cannot follow it.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Maintains the Writing plain-language health information Medium
Secretary (ISCO 3344) Keeps the Patient information test register Medium

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
WTG-SOP-002 · Writing plain-language health information Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)
WTG-REG-001 · Patient information test register Secretary (ISCO 3344) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Reception & Information: The First Ten Minutes (H-02) Manager; Nurse

References

  1. WHO (2020). Patient Engagement: Technical Series on Safer Primary Care. Used for: Patient engagement in primary care: information, leaflets, questions and answers. General patient safety series. https://news.gmj.ge/guideline/patient-engagement-technical-series-on-safer-primary-care/
45.5Patients Can Ask Questions and Get AnswersHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Patients can ask questions at any point and receive an answer they understand. The use of teach-back to check understanding is recorded for key decisions.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

Why it matters. Patients who cannot ask questions, or who do not get answers they understand, cannot take part in their care. Making it possible to ask at any point keeps the patient involved.

How the surveyor verifies this criterion

Sample. Review patient questions and their answers, and the teach-back records for key decisions, over the sample period.

1. Patients can ask questions at any point and receive an answer they understand.

Method. Observe consultations and check the question and feedback records for the sample.

Evidence to show. Patient questions and teach-back (WTG-POL-002).

Pass when. Every sampled question received an answer the patient understood.

2. Teach-back is used for key decisions, and its use is recorded.

Method. Check the teach-back record for each key decision in the sample.

Evidence to show. Teach-back record for key decisions (WTG-FRM-003).

Pass when. Every key decision in the sample has a teach-back record.

Immediate fail (any one means the criterion is not met). A patient signs a consent form for surgery without understanding the risks, and no one checks.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Maintains the Patient questions and teach-back (WTG-POL-002); complaints and feedback Medium
Nurse (ISCO 2221) Completes the Teach-back record for key decisions Medium

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
WTG-FRM-003 · Teach-back record for key decisions Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)
WTG-POL-002 · Patient questions and teach-back Chief executive (ISCO 1120) Governing body members N/A Chief executive (ISCO 1120) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Reception & Information: The First Ten Minutes (H-02) Manager; Nurse

References

  1. WHO (2020). Patient Engagement: Technical Series on Safer Primary Care. Used for: Patient engagement in primary care: information, leaflets, questions and answers. General patient safety series. https://news.gmj.ge/guideline/patient-engagement-technical-series-on-safer-primary-care/
  2. World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705 Used for: https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/

Who is responsible for Standard 45

Each criterion names the positions responsible for it. Every position links to its own terms of reference.

Criterion Responsible Supports
45.1 Waiting Times Are Measured and Shared Patient services manager
Bed manager / patient flow coordinator
Clinical audit officer
45.2 Patients in Urgent Need Are Not Left Unseen Triage nurse
Head of emergency department
Emergency nurse
45.3 Waiting Patients Are Kept Informed Receptionist
Patient services manager
Triage nurse
45.4 Health Information Is in Plain Language Complaints and patient experience officer
Patient advocate
Quality manager
45.5 Patients Can Ask Questions and Get Answers Complaints and patient experience officer
Patient advocate
Consultant physician (internal medicine)

Role details: reporting, supervision and training

Training shown is the general recommendation. Role-specific training is set in the next improvement round.

Role Reports to Supervises Recommended training
Quality manager Chief quality and safety officer Quality assurance officer, Patient safety officer, Accreditation coordinator, Clinical audit officer, Infection prevention and control (IPC) lead, Complaints and patient experience officer Facility induction; safeguarding adults (general recommendation)
Clinical audit officer Quality manager Medical records quality auditor Facility induction; safeguarding adults (general recommendation)
Complaints and patient experience officer Quality manager None Facility induction; safeguarding adults (general recommendation)
Consultant physician (internal medicine) Head of department (per specialty) Resident physician / house officer Facility induction; safeguarding adults (general recommendation)
Emergency nurse Head of department (per specialty) None Facility induction; safeguarding adults (general recommendation)
Patient advocate Complaints and patient experience officer None Facility induction; safeguarding adults (general recommendation)
Head of emergency department Medical director Triage nurse, Emergency nurse Facility induction; safeguarding adults (general recommendation)
Triage nurse Head of emergency department None Facility induction; safeguarding adults (general recommendation)
Patient services manager Chief operating officer (COO) Admissions officer, Receptionist, Appointments clerk, Medical records manager, Bed manager / patient flow coordinator Facility induction; safeguarding adults (general recommendation)
Receptionist Patient services manager None Facility induction; safeguarding adults (general recommendation)
Bed manager / patient flow coordinator Patient services manager None Facility induction; safeguarding adults (general recommendation)

Questions and answers

The criterion text is the authority. These answers summarise it.

Who does Standard 37 apply to?

Health services with reception areas and waiting rooms, including hospitals, clinics and urgent care, and the staff who give patients information.

What do the colours mean for this standard?

Red (Must) is required. Green (Medium) is recommended. Yellow (Minimum) is the lowest acceptable level in humanitarian settings. Standard setting is Must on every criterion.

Are waiting times measured?

Under 45.1 waiting times are measured from arrival or booking, compared with a target, and shared with patients and staff.

Can an urgent patient wait unseen?

No. Under 45.2 patients are assessed for urgency on arrival, and those whose condition may change while they wait are reassessed at set intervals and when it changes.

Are patients kept informed while they wait?

Under 45.3 patients who wait are told the reason, given an updated estimate where it changes, and told what to do if they need help.

Is health information written in plain language?

Under 45.4 written information is in plain language, tested with the people who will use it, and available in the languages the population uses.

Can patients ask questions and get answers?

Under 45.5 patients can ask questions at any point and get an answer they understand, and teach-back is recorded for key decisions.

Guidelines for this standard

3 guideline(s) are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.

  1. Managing Waiting Times: A Good Practice Guide (Scottish Gov)
  2. Management and Review of ‘Did Not Wait’ Patients that Present to Emergency Services (WA Country Health Service)
  3. Patient Engagement: Technical Series on Safer Primary Care (World Health Organization)