Botswana Hospital Standards V2

BOTSWANA HOSPITAL STANDARDS V2
STANDARDS AND CRITERIA
CONFIDENTIAL
COUNCIL FOR HEALTH SERVICE ACCREDITATION OF SOUTHERN AFRICA
Office Suite 8, Lonsdale Building, Lonsdale Way, Pinelands, Cape Town
Tel: (021) 531-4225/6 Fax: (021) 531-4243
Cohsasa's Mission
Assist healthcare facilities to deliver safe and effective care through sustained quality improvement and
internationally recognised accreditation
Accredited by:
 STANDARDS ASSESSMENT REFERENCE DOCUMENT
Date generated: 16/03/2010

TABLE OF CONTENTS
HEALTH CARE ORGANISATION MANAGEMENT 5
SE 1 Management and Leadership 5
SE 2 Human Resource Management 15
SE 3 Administrative Support 25
SE 4 Access to Care 31
SE 5 Patient and Family Rights 37
SE 6 Management of Information 47
SE 7 Health and Safety 53
SE 8 Quality Management and Improvement 61
SE 9 Prevention and Control of Infections 71
CARE OF PATIENTS 77
Inpatient units 77
SE 10 Medical/Surgical/Paediatric & Obstetrics 77
SE 11 Medical Care 93
SE 12 Surgical Care 109
SE 13 Critical Care 125
SE 14 Obstetric/Maternity Care 139
SE 15 Psychiatric Care (Ward) 155
SE 16 Paediatric Care 171
Diagnostic and treatment support services 187
SE 17 Operating Theatre and Anaesthesia services 187
SE 18 Nuclear Medicine 197
SE 19 Laboratory service 205
SE 20 Radiology service 211
SE 21 Pharmaceutical service 217
Ambulatory care 225
SE 22 Emergency Care 225
SE 23 Outpatient Care 239
SE 24 Ambulatory Care 253
ANCILLARY SERVICES 269
SE 25 Sterilising and Disinfecting Unit 269
SE 26 Food Service 275
SE 27 Laundry Service 281
SE 28 Housekeeping Service 287
Date generated: 16/03/2010 Page 3 of 419

SE 29 Maintenance service 293
SE 30 Resuscitation Service 301
SE 31 Healthcare Technology Management 305
PROFESSIONAL SERVICES 313
SE 32 Physiotherapy Service 313
SE 33 Occupational Therapy Service 319
SE 34 Dietetic Service 325
SE 35 Speech Therapy Service 331
SE 36 Clinical Psychology Service 337
SE 37 Social Work Service 343
SE 39 Dental Service 349
SPECIALISED SERVICES 361
SE 40 Psychiatric Care (Hospital) 361
SE 41 Medical Oncology 403

HEALTH CARE ORGANISATION MANAGEMENT
1.Management and Leadership
Overview of Management and Leadership

Providing excellent patient care requires effective management and leadership, which occur at various
levels in a healthcare organisation. At the governance level there is an entity (for example a ministry of
health), an owner(s), or group of identified individuals (for example a board or governing body)
responsible for directing the operation of the organisation and accountable for providing quality
healthcare services to its community or to the population that seeks care.
Within the organisation there are individuals assigned the responsibility of ensuring that the policies of
governance are implemented, and that there are systems of administration and organisation to provide
excellent patient care.
At departmental and service level, heads of departments and services ensure effective management
and leadership.
Leadership comes from many sources in a healthcare organisation, including governing leaders,
clinical and managerial leaders, and others who hold positions of leadership, responsibility and trust.
Each organisation must identify these individuals and involve them in ensuring that the organisation is
an effective, efficient resource for the community and its patients.
In particular, these leaders must identify the organisation's mission and make sure that the resources
needed to fulfil this mission are available. For many organisations, this does not mean adding new
resources but using current resources more efficiently - even when they are scarce. Also, leaders
must work well together to co-ordinate and integrate all the organisation's activities, including those
designed to improve patient care and clinical services.
Effective governance, management and leadership begin with understanding the various
responsibilities and authority of individuals in the organisation, and how these individuals work
together.
Those who provide governance, management, and/or leadership have both authority and
responsibility. Collectively and individually they are responsible for complying with laws and
regulations, and for meeting the organisation's responsibility to the patient population served.
Over time, effective management and leadership helps overcome perceived barriers and
communication problems between departments and services in the organisation, and the organisation
becomes more efficient and effective. Services become increasingly integrated. In particular, the
integration of all quality management and improvement activities throughout the organisation results in
improved patient outcomes.

Standards
1.1. Governance of the organisation

1.1.1. The responsibilities and accountability of the governance of the organisation
are documented and implemented by the organisation’s managers.
Intent of 1.1.1
There is a governing body responsible for directing the operation of the organisation, which is
accountable for providing quality healthcare services to its community or to the population that seeks
care. The responsibilities and accountability of this entity are described in a document that identifies
how they are to be carried out, and are known to those responsible for management within the
organisation.
It is important that the organisation has clear leadership, operates efficiently, and provides quality
healthcare services. The lines of communication to achieve this are presented in an organisational
chart or other document. The identification of individuals in a single organisational chart does not, by
itself, ensure good communication and co-operation between those who govern and those who
manage the organisation. This is particularly true when the governance structure is separate from the
organisation, such as a distant owner or national or regional health authority. The process for
communication and co-operation with the governance must therefore be made known to the
organisation's managers and be employed by them.
The responsibilities of governing bodies lie primarily in approving plans and documents submitted by
the managers of the organisation. Those elements of management requiring approval by governance
are documented. The hospital board's relationship with governance and management of the hospital
are described in written documents.
1.1.1 Criteria
1.1.1.1. The organisation’s governance structure is described in written documents, which are known to the
staff in the organisation.
1.1.1.2. The documents describe governance responsibilities and accountability.
1.1.1.3. There is an organisational chart or document that describes the lines of authority and accountability
from governance, and within the organisation.
1.1.1.4. Those responsible for governing and managing are identified by title or post designation.
1.1.1.5. The responsibilities of governance are made known to the staff of the organisation relating to the
granting of approval of the mission, plans, and policies and procedures.
1.1.1.6. The responsibilities of governance are made known to the staff of the organisation relating to
allocation of the organisation’s budget.
allocation of the resources required to meet the organisation’s mission.
appointment of the organisation’s senior manager.
1.1.1.9. The responsibilities of governance are made known to the staff of the organisation relating to support
and promotion of quality management and improvement.
promotion of community involvement in the planning and implementation of health services provided
by the organisation.
communication and co-operation between the organisation’s governance and management and the
community.
1.2. Management of the organisation

1.2.1. A senior manager is responsible for operating the organisation within

applicable laws and regulations.
Intent of 1.2.1
The senior manager is appointed by the governing body to be responsible for the overall, day-to-day
operation of the organisation. These responsibilities are documented and known to the staff of the
organisation. The individual appointed to carry out these functions has the education and experience
to do so.
The senior manager is responsible for the implementation of all policies, which have been approved by
the governing body.
1.2.1 Criteria
1.2.1.1. The senior manager manages the day-to-day operation of the organisation.
1.2.1.2. The senior manager has the education and experience to carry out his or her responsibilities.
1.2.1.3. The senior manager carries out approved policies.
1.2.1.4. The senior manager assures compliance with applicable laws and regulations.
1.2.1.5. The senior manager responds to any reports from inspecting and regulatory agencies.
1.2.1.6. The senior manager manages human, financial and other resources.
1.2.1.7. The senior manager implements processes to manage and control human, financial and other
resources.
1.2.2. The organisation’s clinical and managerial leaders are identified and are
collectively responsible for defining the organisation’s mission and creating the plans
and policies needed to fulfil the mission.
Intent of 1.2.2
While managers are appointed to posts and have a leadership role, leaders of an organisation may
arise from many sources. These leaders may represent every service in the organisation, e.g.
medical, nursing, maintenance, administration, physiotherapy and radiography. Leaders may also be
nominated or elected to certain committees, ie health and safety committees and infection control
committees. Effective leadership is essential for a healthcare organisation to be able to operate
efficiently and fulfil its mission. Leadership is what individuals provide together and individually to the
organisation and can be carried out by any number of individuals.
Leaders may have formal titles, or be informally recognised for their seniority, stature, or contribution to
the organisation. It is important that all the leaders of an organisation are recognised and brought into
the process of defining the organisation's mission. The leaders work collaboratively to develop the
plans and policies needed to fulfil the mission.
1.2.2 Criteria
1.2.2.1. The leaders of the organisation are formally or informally identified.
1.2.2.2. The leaders are collectively responsible for defining the organisation’s mission.
1.2.2.3. The leaders are collectively responsible for ensuring that the mission statement is known to all staff,
patients, carers and the community served.
1.2.2.4. The leaders work collaboratively to carry out the mission of the organisation.
1.2.2.5. The leadership roles in various positions are documented, agreed to, and known by the staff.
1.2.3. The organisation provides patient care within business, financial, ethical and
legal norms.

Intent of 1.2.3
The organisation has established and implemented a framework for ethical management that includes
marketing, admissions, transfers and discharges, and disclosure of ownership and any business and
professional conflicts that may not be in the patients' best interests.
A healthcare organisation has ethical and legal responsibilities to the patients and community it serves.
The leaders understand those responsibilities as they apply to the business and clinical activities of
the organisation. The leaders create guiding documents, such as the organisation's mission, to
provide a consistent framework to carry out those responsibilities. The organisation operates within
this framework to:
• disclose ownership and any conflicts of interest;
• honestly portray its services to patients;
• provide clear guidelines for the levels of care and services offered;
• accurately bill for its services, and
• resolve conflicts when financial incentives and payment arrangements could compromise patient
care.
1.2.3 Criteria
1.2.3.1. The organisation’s leaders establish ethical and legal norms that protect patients and their rights.
1.2.3.2. The leaders make public the organisation’s mission statement.
1.2.3.3. The leaders establish a framework for the ethical management of the organisation.
1.2.3.4. The organisation discloses its ownership.
1.2.3.5. The organisation honestly portrays its services to patients.
1.2.3.6. The organisation provides clear admission, transfer and discharge policies.
1.2.3.7. The organisation accurately bills for services.
1.2.3.8. The organisation discloses and resolves conflicts when financial incentives and payment
arrangements compromise patient care.
1.2.4. The organisation’s leaders ensure that policies and procedures are
implemented to support the activities of the organisation and to guide the staff,
patients and visitors.
Intent of 1.2.4
Policies and procedures are formulated at different levels of authority, e.g. national Acts and
regulations, national health and labour departmental policies, regional policies and organisational
policies.
Leaders must ensure that all policies which apply to the organisation are available to the staff, and that
they are implemented and monitored as they relate to various departments, services and functions.
Leaders should ensure that policies and procedures are available to guide the staff in such matters as
allocation, use and care of resources, financial practices, human resource management and dealing
with complaints from patients and visitors.
1.2.4 Criteria
1.2.4.1. The organisation’s leaders ensure that policies and procedures guide and support the activities and
management of the organisation.
1.2.4.2. A designated manager is responsible for compiling and indexing of policies and procedures, and
ensuring their circulation, recall and review.
1.2.4.3. Policies and procedures are signed by persons authorised to do so.

1.2.4.4. Policies and procedures are compiled into a comprehensive manual, which is indexed and easily
accessible to all staff.
1.2.4.5. All policies and procedures are reviewed at appropriate intervals, dated and signed.
1.2.4.6. There is a mechanism to ensure that policies are known and implemented.
1.2.5. The organisation’s leaders plan for the type of services required to meet the
needs of the patients served by the organisation, in consultation with community
members and/or other stakeholders.
Intent of 1.2.5
An organisation's mission statement usually reflects the needs of its patient population, and patient
care services are designed and planned to respond to those needs. Similarly, referral and specialty
hospitals derive their mission from the needs of patients within larger geographic or political areas.
Patient care services are planned and designed to respond to the needs of the patient population.
The leaders of the various clinical departments and services in the organisation determine what
diagnostic, therapeutic, rehabilitative and other services are essential to the community, and their
scope and intensity. These are defined in a mission statement for each department or service. In
private healthcare organisations those persons who have an interest or a share in the service will need
to be consulted in the planning processes.
1.2.5 Criteria
1.2.5.1. The care and services to be provided are described in the strategic plans of the organisation.
1.2.5.2. The organisation identifies those recognised community leaders and/or other stakeholders to be
included in the planning.
1.2.5.3. The care and services to be offered are consistent with the mission of the organisation.
1.2.5.4. The types of care and services to be provided by the organisation have been determined by clinical
leaders, and departments/services contribute to the facility's strategic plan.
1.2.5.5. The organisation’s leaders plan with the leaders of other provider organisations in their community.
1.2.6. Organisation leaders plan for the type of HIV services required to meet the
needs of the patients served by the facility, in consultation with community members
and/or stakeholders.
1.2.6 Criteria
1.2.6.1. Management ensures that suitably qualified/trained/experienced staff are available to provide a
comprehensive HIV/AIDS programme.
1.2.6.2. Management ensures that HIV/AIDS management is monitored and supported as an integral
component of the overall hospital management.
1.2.6.3. Management ensures that set targets for patients receiving Anti-Retroviral Therapy are met.
1.2.6.4. Management ensures that set targets for VCT/RHT are met.
1.2.6.5. Management ensures that set targets for PMCTC are met.
1.2.7. The organisation has a committee or another way of controlling all research in
the organisation involving patients.
Intent of 1.2.7
When the organisation conducts clinical research, investigations or trials that involve patients, a
committee or other mechanism to control all such activities in the organisation is established. The
organisation develops a statement of purpose for these activities, which includes the review process
for all research protocols, a process to weigh the relative risks and benefits to the patients, and

processes related to the confidentiality and security of the research information.

1.2.7 Criteria
1.2.7.1. The organisation has a committee or other mechanism to control all research undertaken within the
organisation.
1.2.7.2. The organisation develops a clear statement of purpose for the control of such activities.
1.2.7.3. Control includes a review process.
1.2.7.4. Control includes a process to weigh relative risks and benefits to subjects.
1.2.7.5. Control includes a process to ensure the confidentiality and security of research information.
1.2.8. The leaders direct the development and monitor the implementation of
contracts for clinical or managerial services.
Intent of 1.2.8
Organisations frequently have the option to provide clinical and managerial services directly, or to
arrange for such services through referral, consultation, contractual arrangements, or other
agreements. Such services may range from radiology services to financial accounting services.
In all cases, the leaders supervise such contracts or other arrangements to ensure that the services
meet patient needs and are monitored as part of the organisation's quality management and
improvement activities.
1.2.8 Criteria
1.2.8.1. There is a process for leaders to supervise contracts.
1.2.8.2. Services provided under contracts and other arrangements meet patient needs.
1.2.8.3. Contracts and other arrangements are monitored as part of the organisation’s quality management
and improvement programme.
1.2.8.4. Copies of contracts are made available to those who ensure their implementation.
1.2.9. The organisation’s leaders foster communication between individuals and co-
ordinate services among departments.
Intent of 1.2.9
To co-ordinate and integrate patient care, the leaders develop a culture that emphasises co-operation
and communication. The leaders develop formal methods (e.g. standing committees, joint teams),
and informal methods (e.g. newsletter, posters) for promoting communication among services and
individual staff members. Relevant community members become part of the communication network.
Co-ordination of clinical services comes from an understanding of the mission and services of each
department and service, and collaboration in the development of common policies and procedures.
Medical, nursing and other clinical leaders have a special responsibility to patients and to the
organisation. These leaders:
• support good communication between professionals;
• jointly plan and develop policies that guide the delivery of clinical services;
• provide for the ethical practicing of their professions; and
• monitor the quality of patient care.
The leaders of the medical and nursing staff create a suitable, effective organisation structure to carry
out those responsibilities. The organisational structure(s), and the associated processes used to carry
out those responsibilities, can provide a single professional staff comprised of physicians, nurses and
others, or can provide separate medical and nursing staff structures. The structure chosen can be

highly organised with bylaws and rules and regulations. In general, the structure(s) chosen is (are):
• inclusive of all the relevant clinical staff;
• consistent with the ownership, mission and structure of the organisation;
• appropriate for the complexity of the organisation and size of the professional staff; and
• effective in carrying out the responsibilities listed above.
1.2.9 Criteria
1.2.9.1. The organisation’s leaders foster communication among departments, services, individual staff
members and community leaders and groups.
1.2.9.2. The organisation’s leaders foster co-ordination of clinical services.
1.2.9.3. Agendas are prepared for meetings, and the staff are given timely notification in order to prepare for
participation.
1.2.9.4. Minutes of meetings are taken and are circulated to all relevant staff.
1.2.9.5. There is a mechanism to ensure that key issues resulting from meetings of the Board and/or the
management of the organisation are communicated to and acted upon by the staff.
1.2.9.6. Medical, nursing and other clinical leaders plan and implement an effective organisational structure to
support their responsibilities and authority.
1.2.9.7. The organisational structure and processes support professional communication.
1.2.9.8. The organisational structure and processes support clinical planning and policy development.
1.2.9.9. The organisational structure and processes support handling of professional ethical issues.
1.2.9.10. The organisational structure and processes support monitoring of the quality of clinical services.
1.2.9.11. The structure is appropriate for the organisation’s size and complexity.
1.3. Management of departments and services

1.3.1. Identified departmental or service managers control clinical and managerial
activities in each department or service.
Intent of 1.3.1
The clinical care, patient outcomes and overall management of a healthcare organisation are only as
good as the clinical and managerial activities of each individual department or service.
Good departmental or service performance requires clear leadership from a qualified individual. The
qualifications of departmental managers should be appropriate to the department, ie suitable
paediatric, ICU, operating theatre or information technology qualifications, as applicable. In large
departments or services, clinical and administrative leadership may be separate. In such a case the
responsibilities of each role are defined in writing.
Documents prepared by each department define its goals, identify current and planned services, and
establish the knowledge, skills and availability of staff required to assess and meet patient care needs.
Clinical services provided are co-ordinated and integrated within each department or service. For
example, there is integration of medical and nursing services. Also, each department or service works
to co-ordinate and integrate its services with other departments and services. The management of the
organisation's organisational chart guides departmental/service staff in adhering to correct lines of
communication. Each department or service documents the lines of communication within that
department or service. Unnecessary duplication of services is avoided or eliminated to conserve
resources.
1.3.1 Criteria

1.3.1.1. The organisation ensures that one or more qualified individuals manage each department or service
in the organisation.
1.3.1.2. These individuals have appropriate training, education and experience to manage the particular
department or service.
1.3.1.3. Departmental and service managers are identified by title or post.
1.3.1.4. The responsibilities of each departmental manager are defined in writing.
1.3.1.5. The departmental/service manager is responsible for its day-to-day operation.
1.3.1.6. Departmental managers identify the services to be provided by the department, in consultation with
the organisation’s management.
1.3.1.7. These services are described in written documents.
1.3.1.8. Policies and procedures guide the provision of identified services.
1.3.1.9. Policies and procedures address the staff knowledge and skills needed to assess and meet patient
needs.
1.3.1.10. Policies and procedures address the required number of staff available at each shift.
1.3.1.11. Departmental managers implement quality control programmes when indicated.
1.3.1.12. There is co-ordination and integration of services with other departments and services.
1.3.2. Policies and procedures and applicable laws and regulations guide the uniform
care of all patients.
Intent of 1.3.2
As patients move through a healthcare organisation from entry to discharge or transfer, several
departments and services as well as many different healthcare providers may be involved in providing
care. Throughout all phases of care, patient needs are matched with the appropriate resources within
and, when necessary, outside the organisation. This is commonly accomplished by using established
criteria or policies that determine the appropriateness of transfers within the organisation.
For patient care to appear seamless, the organisation needs to design and implement processes for
continuity and co-ordination of care among physicians, nurses and other care providers in:
• emergency services and inpatient admission;
• diagnostic and treatment services;
• surgical and non-surgical services; and
• the organisational and other care settings.
The leaders of the various care settings and services work together to design and implement the
processes. The processes may be supported by explicit transfer criteria or by policies, procedures, or
guidelines. The organisation identifies individuals responsible for co-ordinating patient care (for
example between departments) or for co-ordinating the care of individual patients (for example the
case manager).
Patients with the same health problems and care needs have a right to receive the same quality of
care throughout the organisation. To carry out the principle "one level of quality of care" requires that
the clinical and managerial leaders plan and co-ordinate the care provided to patients. In particular,
services provided to similar patient populations in multiple departments or care settings are guided by
policies and procedures that result in uniform delivery. Those policies and procedures respect
applicable laws and regulations that shape the care process and are best developed collaboratively.
Uniform patient care is reflected in the following:
• access to and appropriateness of care and treatment do not depend on the patient's ability to pay
or on the source of payment;
• the seriousness of the patient's condition determines the resources allocated to meet the patient's
needs;
• the level of care provided to patients (for example anaesthetic care) is the same throughout the

organisation; and
• patients with the same nursing care needs receive comparable levels of nursing care throughout
the organisation.
Uniform patient care results in the efficient use of resources and permits the evaluation of outcomes of
similar care processes throughout the organisation.
1.3.2 Criteria
1.3.2.1. The organisation’s clinical and managerial leaders collaborate to provide uniform care processes.
1.3.2.2. When similar care is provided in more than one setting, care delivery is uniform.
1.3.2.3. Policies and procedures guide uniform care and reflect relevant laws and regulations.
1.3.2.4. Care planning is integrated and co-ordinated among care settings, departments and services.
1.3.2.5. Care delivery is integrated and co-ordinated among care settings, departments and services.
1.3.2.6. There is a clinical record for each patient, and the specific content requirements of clinical records
have been determined by the organisation.
1.3.3. Departmental or service managers recommend space, staffing and other

resources needed by the department or service to the organisation’s management.
Intent of 1.3.3
The leaders of each department or service make their human resources and other resource
requirements known to the organisation's senior managers. This helps ensure that adequate staff,
space, equipment and other resources are available to meet patient needs at all times. The
organisation's management provides departmental and service managers with data and information
needed to manage and improve care and service.
Patient care is not provided when special resources are not available.
1.3.3 Criteria
1.3.3.1. Departmental or service managers recommend the space needed to provide the specified patient
services.
1.3.3.2. Departmental or service managers recommend the staff needed to provide those services.
1.3.3.3. Departmental or service managers recommend the other special resources needed to provide those
services.
1.3.3.4. Departmental or service managers recommend the required criteria related to the education, skills,
knowledge and experience of professional staff.
1.3.3.5. The organisation’s management uses such criteria in the selection of professional staff, in
consultation with departmental or service managers.
1.3.3.6. Departmental or service managers provide orientation and training for all staff of the department or
service appropriate to their responsibilities.


2.Human Resource Management
Overview of Human Resource Management

A healthcare organisation needs an appropriate number of suitably qualified people to fulfil its mission
and meet patient needs. The organisation's clinical and administrative leaders work together to
identify the number and types of staff needed based on the recommendations from departmental
managers.
Recruiting, evaluating and appointing staff members are best accomplished through a co-ordinated,
efficient and uniform process. It is also essential to document an applicant's skills, knowledge,
education and previous work experience. It is particularly important to carefully review the credentials
of medical and nursing staff because they are involved in clinical care processes and work directly with
patients.
Healthcare organisations should provide their staff with opportunities to learn and advance personally
and professionally. Thus, in-service education and other learning opportunities should be offered to
the staff.

Standards
2.1. Staff planning

2.1.1. The organisation’s leaders plan for the provision of adequate numbers of
suitably qualified staff.
Intent of 2.1.1
Appropriate and adequate staffing is critical to patient care. The organisation's clinical and
managerial leaders carry out staff planning using recognised methods for determining levels of
staffing. For example, a patient acuity system is used for determining the number of registered nurses
with paediatric intensive care experience required to staff a ten-bed paediatric intensive care unit.
The organisation's leaders define the desired educational, skills, knowledge and any other
requirements as part of projecting staff complements and needs.
Staff retention, rather than recruitment, provides greater long-term benefit. Retention is increased
when leaders support staff development. Thus, the leaders collaborate to plan and implement uniform
programmes and processes related to the recruitment, retention and development of all staff.
There is a written plan, which identifies the numbers and types of required staff, and the skills,
knowledge and other requirements needed in each department and service. The plan is designed to
address:
• the reassignment of staff from one department or service to another in response to changing
patient needs or staff shortages;
• the consideration of staff requests for reassignment, based on cultural values or religious beliefs;
and
• the policies and procedures for transferring responsibility from one individual to another (for
example, from a physician to a nurse) when the responsibility would fall outside such an individual's
normal area of responsibility.
Planned and actual staffing are monitored on an ongoing basis and the plan is updated as necessary.
When monitored on a departmental or service level, there is a collaborative process for the clinical
and managerial leaders of the organisation to update the overall plan.
2.1.1 Criteria
2.1.1.1. There is a written plan for staffing the organisation.
2.1.1.2. The planning process includes staff recruitment.
2.1.1.3. The planning process includes staff retention.
2.1.1.4. The planning process includes personal development of the staff.
2.1.1.5. The clinical and managerial leaders developed the plan collaboratively.
2.1.1.6. The numbers, types and desired qualifications of staff are identified in the plan.
2.1.1.7. The plan addresses the assignment and reassignment of staff members.
2.1.1.8. The organisation’s mission, mix of patients, services provided and technology used are considered in
the planning.
2.1.1.9. The desired education, skills and knowledge are defined for staff members.
2.1.1.10. Applicable laws and regulations are incorporated into the planning.
2.1.1.11. The effectiveness of the staffing plan is monitored on an ongoing basis.
2.1.1.12. Revision and updating are done when necessary.
2.1.2. The organisation’s leaders develop and implement processes for recruiting,
evaluating and appointing staff.

Intent of 2.1.2
The organisation provides an efficient, co-ordinated or centralised process for
• recruiting individuals for available positions;

• evaluating the training, skills and knowledge of candidates; and
• appointing individuals to the organisation's staff.
If the process is not centralised, similar criteria, processes and forms result in a uniform process
across the organisation. Departmental and service managers participate by recommending the
number and qualifications of the various categories of staff needed to provide clinical services to
patients and to fulfil any teaching or other departmental responsibilities. Departmental and service
managers also help make decisions about individuals to be appointed to the staff.
Qualified staff are hired through a process that matches the requirements of the position with the
qualifications of the prospective staff member. When hired, the new staff member is further evaluated
to ensure that he or she can actually assume these responsibilities detailed in his or her job
description. This evaluation is carried out at the time of starting the job. The department or service to
which the staff member is assigned carries out this evaluation of necessary skills and knowledge and
of desired work behaviours. Thus, the standards in this chapter complement the Management and
Leadership standards that describe a departmental or service manager's responsibilities.
2.1.2 Criteria
2.1.2.1. There is a process in place to recruit staff.
2.1.2.2. There is a process in place to verify the qualifications/experience of new staff members.
2.1.2.3. There is a process in place for appointing individuals to the staff.
2.1.2.4. The process is uniform across the organisation.
2.1.2.5. The process is implemented.
2.2. Personnel management

2.2.1. Each staff member’s responsibilities are defined in a current job description.
Intent of 2.2.1
Individual staff members who are not registered to practice independently have their responsibilities
defined in a current job description. The job description is the basis for assignment, orientation to their
work, and evaluation of how well they fulfill job responsibilities.
2.2.1 Criteria
2.2.1.1. Staff members employed by the organisation have a written job description, which defines their
responsibilities.
2.2.1.2. Job descriptions are current.
2.2.1.3. Staff members sign that they are in agreement with the job description.
2.2.2. Sound industrial relations, which are based on current labour legislation, are
implemented and maintained in the organisation.
Intent of 2.2.2
Consistent application of fair labour practice, grievance and disciplinary procedures, and dismissal,
demotion and retrenchment policies and procedures is essential to prevent labour unrest, with its
consequent negative effects on patient care. Membership of staff in trade unions and/or health

professional organisations must be encouraged, and there must be negotiation and consultation
between these bodies, management of the organisation and the staff to promote harmonious working
relationships. Current employment policies need to be known and applied.
The organisation's leaders thus have a responsibility to:
• be conversant with all current labour laws and regulations;
• educate personnel managers in relevant aspects of labour law;
• ensure that policies and procedures are developed;
• ensure that these policies and procedures are effectively implemented.
2.2.2 Criteria
2.2.2.1. There are mutually agreed policies and procedures with the staff for the satisfactory conduct of
industrial relations activities.
2.2.2.2. Written disciplinary procedures, which meet the requirements of current legislation, are available.
2.2.2.3. There is a grievance procedure in terms of current legislation.
2.2.2.4. There are dispute and appeal procedures.
2.2.2.5. There are recognition agreements for trade unions and/or health professional organisations.
2.2.2.6. There is consistent application of fair employment and labour practices, which comply with current
legislation.
2.2.3. The organisation uses a defined process to evaluate staff knowledge and skills
to ensure that these are consistent with patient needs.
Intent of 2.2.3
The organisation complies with laws and regulations that define desired educational level, skill, or
other requirements of individual staff members, or define staffing numbers or mix of staff for the
organisation. The organisation considers the mission of the organisation, and needs of patients in
addition to requirements of laws and regulations.
The organisation defines the process for and the frequency of the ongoing evaluation of staff abilities.
Ongoing evaluation ensures that training occurs when needed and that the staff member is able to
assume new or changed responsibilities. While such evaluation is best carried out in an ongoing
manner, there is a least one documented evaluation each year for each staff member.
2.2.3 Criteria
2.2.3.1. The organisation uses a defined process to match staff knowledge and skills to patient needs.
2.2.3.2. Managers implement quality monitors that address the responsibilities of staff members in their
department or service.
2.2.3.3. There is at least one documented evaluation of each staff member each year or more frequently as
defined by the organisation.
2.2.3.4. New staff members are evaluated in accordance with the policies determined by the organisation.
2.2.3.5. The department or service to which the individual is assigned conducts the evaluation.
2.3. Staff orientation and education

2.3.1. All staff members are orientated to the organisation and to their specific job
responsibilities at the time of appointment.
Intent of 2.3.1
The decision to appoint an individual to the staff of an organisation sets several processes in motion.
To perform well, a new staff member needs to understand the workings of the entire organisation and

how his or her specific responsibilities contribute to the organisation's mission. This is accomplished
through a general orientation to the organisation and his or her role in the organisation, and a specific
orientation to the job responsibilities of his or her position. The organisation includes, as appropriate,
the reporting of medical errors, infection control practices, the organisation's policies on telephonic
medication orders, and so on. Contract workers/volunteers and volunteers are also orientated to the
organisation and their specific assignment or responsibilities, such as patient safety and infection
control.
2.3.1 Criteria
2.3.1.1. There are written programmes for staff orientation to the organisation.
2.3.1.2. New staff members are orientated to the organisation.
2.3.1.3. Departmental and service managers have established an orientation programme for departmental
and service staff.
2.3.1.4. Contract workers/volunteers are orientated to the organisation, their job responsibilities and their
specific assignments.
2.3.2. Each staff member receives ongoing in-service education and training to
maintain or advance his or her skills and knowledge, based on identified needs.
Intent of 2.3.2
The organisation has a responsibility to ensure that staff members are educated in matters which
affect their functioning in the specific organisation. In particular, the staff are trained in health and
safety matters, infection control and cardiac life support. The organisation also collects and integrates
data from several sources to understand the ongoing educational needs of the staff. Such sources
include monitoring data from the facility management programme, the introduction of new technology,
skills and knowledge areas identified through the review of job performance, new clinical procedures,
and future plans and strategies of the organisation.
Education is relevant to each staff member as well as to the continuing advancement of the
organisation in meeting patient needs and maintaining acceptable staff performance, teaching new
skills, and providing training on new equipment and procedures. There is documented evidence that
each staff member who has attended training has gained the required competencies.
Each department or service manager ensures that in-service training is provided to the staff of the
particular department or service. For example, medical staff members may receive education on
infection control, advances in medical practice, or new technology. Information management staff
may be provided with in-service training on computer software, and technicians may receive on-the-job
training relating to repair of equipment.
The leaders of the organisation support the commitment to ongoing staff in-service education by
making available space, equipment and time for education and training programmes. The education
and training can take place in a centralised location or in several smaller learning and skill
development locations throughout the facility. The education can be offered once to all or repeated
for all staff on a shift-by-shift basis so as to minimise the impact on patient care activities.
2.3.2 Criteria
2.3.2.1. The organisation has a written plan for staff education and training.
2.3.2.2. Department and service managers have established in-service training programmes relevant to
departmental and service staff.
2.3.2.3. The organisation uses various sources of data and information to identify staff education needs.

2.3.2.4. Education programmes are planned based on this data and information.
2.3.2.5. Organisation staff are provided with ongoing in-service education and training.
2.3.2.6. The education is relevant to each staff member’s ability to meet patients’ needs.
2.3.2.7. The organisation provides facilities and equipment for staff in-service education and training.
2.3.2.8. The organisation provides adequate time for all staff to participate in relevant education and training
opportunities.
2.3.2.9. The organisation ensures that educators are available to provide staff education.
2.3.2.10. Staff competencies are assessed and recorded after training.
2.3.3. Staff members participate in continuing education, research, and other

educational experiences to acquire new skills and knowledge and to support job
advancement.
Intent of 2.3.3
The organisation has a process to inform the staff of opportunities for continuing education and
training, participation in research and investigational studies, and to acquire advanced or new skills.
These opportunities may be offered by the organisation, by a staff member's professional or trade
association, or through educational programmes in the community. The organisation supports such
opportunities as appropriate to its mission and resources. Such support may be through tuition
support, scheduled time away from work, recognition for achievement and other ways.
2.3.3 Criteria
2.3.3.1. There is a continuing educational strategy developed by the management of the organisation for all
professional staff in the organisation to fulfil requirements for continued registration with the relevant
professional bodies.
2.3.3.2. There is a development strategy for the organisation that ensures that managers receive the training
required to fulfil their responsibilities.
2.3.3.3. The staff are informed of opportunities to participate in advanced education, training, research, and
other experiences.
2.3.3.4. The organisation supports staff participation in such opportunities.
2.3.3.5. The organisation supports the need for relevant postgraduate qualifications.
2.4. Credentialing of staff

2.4.1. The organisation has an effective process for gathering, verifying and
evaluating the credentials (registration, education, training and experience) of those
health care professionals who are permitted to provide patient care without
supervision.
Intent of 2.4.1
Healthcare professionals who are registered to provide patient care without clinical supervision are
primarily responsible for patient care and care outcomes. These professionals usually include doctors,
dentists, professional nurses, radiographers, and members of other professions allied to medicine. The
organisation identifies those permitted to work independently in compliance with applicable laws and
regulations. The organisation is responsible for ensuring that these individuals are qualified to provide
patient care without clinical supervision, and for specifying the types of care they are permitted to
provide within the organisation. The organisation needs to ensure that it has a qualified health
professional staff that appropriately matches its mission, resources and patient needs.
To ensure such a match, the organisation evaluates staff members' credentials at the time of their
appointment. An individual's credentials consist of an appropriate current registration, completion of

professional education, and any additional training and experience. The organisation develops a
process to gather this information, verify its accuracy where possible, and evaluate it in relation to the
needs of the organisation and its patients. This process can be carried out by the organisation or by
an external agency such as a ministry of health in the case of public organisations. The process
applies to all types and levels of employed persons (employed, honorary, contract and private
practitioners).
Evaluating an individual's credentials is the basis for two decisions: whether this individual can
contribute to fulfilling the organisation's mission and meeting patient needs, and, if so, what clinical
services this individual is qualified to perform.
These two decisions are documented, and the latter decision is the basis for evaluating the individual's
ongoing performance.
2.4.1 Criteria
2.4.1.1. Those permitted by law, regulation and the organisation to provide patient care without supervision
are identified.
2.4.1.2. The registration, education, training and experience of these individuals are documented.
2.4.1.3. Such information is verified from the original sources when possible.
2.4.1.4. There is a record on every health care professional staff member.
2.4.1.5. The record contains copies of any required registration certificate(s).
2.4.1.6. There is a process to review the records annually.
2.4.1.7. A determination is made about the current qualifications of the individual to provide patient care
services.
2.4.1.8. The organisation has an effective process to authorise all health care professionals to treat patients
and provide other clinical services consistent with their qualifications.
2.4.1.9. The staff member’s registration, education, training and experience are used to authorise the
individual to provide clinical services consistent with his/her qualifications.
2.4.1.10. The services to be provided are made known to appropriate individuals and units of the organisation.
2.4.2. The organisation has an effective process for health care professional staff’s
participation in the organisation’s quality improvement activities.
Intent of 2.4.2
The medical staff's essential clinical roles require them to actively participate in the organisation's
efforts to evaluate their performances and clinical care outcomes. At any point during performance a
staff member's monitoring and evaluation, if his/her performance is in question, the organisation has a
process to evaluate that individual's performance.
2.4.2 Criteria
2.4.2.1. Healthcare staff participate in the organisation’s quality improvement activities.
2.4.2.2. The performance of individual staff members is reviewed when indicated by the findings of quality
improvement activities.
2.4.2.3. The performance of individual staff members is reviewed periodically, as established by the
organisation.
2.5. Human resource management support

2.5.1. Administrative support is provided for the organisation’s human resource
strategy in order for it to meet the need for an adequate number of suitably qualified
and trained staff.
Intent of 2.5.1

A designated individual ensures that administrative support staff provide systems to enable the human
resource strategy to be implemented. This includes the collection, collation and analysis of data to
provide and maintain an effective staffing structure.
Policies and procedures guide administrative support staff in all matters relating to human resource
management, e.g. payment of salaries, allocation of leave, appointments and resignations and
payment of pension benefits.
2.5.1 Criteria
2.5.1.1. A designated individual is responsible for providing support for the organisation’s human resource
strategy.
2.5.1.2. The human resource manager is suitably qualified and experienced in human resource management.
2.5.1.3. The human resource manager ensures that policies and procedures are available to guide the staff
and that they are implemented.
2.5.1.4. Policies and procedures relate to the management of staff appointments, resignations and
terminations of service.
2.5.1.5. Policies and procedures relate to the management of the granting of leave and maintenance of leave
records.
2.5.1.6. Policies and procedures relate to the management of the storage, confidentiality and maintenance of
staff records.
2.5.1.7. The human resource manager uses information on staffing needs provided by clinical and managerial
staff to ensure adequate staff provision.
2.5.1.8. Details of the organisation’s absenteeism, sickness rates and staff turnover rates are recorded and
analysed, to allow for decision-making by the management of the organisation.
2.5.1.9. Details of the staff establishment (ie available posts, filled and vacant posts) are recorded and
analysed to allow for decision-making by the organisation’s management.
2.5.1.10. Receptionists, telephonists and clerical support staff are allocated to wards and departments in
accordance with their needs.
2.5.1.11. All statutory regulations are implemented and records held (e.g. tax, pension fund etc).
2.5.2. A personnel file is maintained for each member of staff.

Intent of 2.5.2
Each staff member in the organisation has a record with information about his or her qualifications,
results of evaluations, and work history. These records are standardised and are kept current.
The confidentiality of personnel records is protected.
Personnel records are safely stored, and their contents are monitored to ensure completeness.
2.5.2 Criteria
2.5.2.1. A designated member of staff is responsible for the storage and retrieval of personnel records.
2.5.2.2. There is documented personnel information on each staff member.
2.5.2.3. Personnel files are standardised.
2.5.2.4. Personnel files are kept current.
2.5.2.5. Personnel files contain
appointment letters/employment contracts.
2.5.2.6. Personnel files contain qualifications of the staff member.
2.5.2.7. Personnel files contain details of staff evaluations.
2.5.2.8. Personnel files contain the work history of the staff member.
2.5.2.9. Personnel files contain a record of in-service education attended by the staff member.
2.5.2.10. Details of staff evaluations are recorded and monitored.
2.5.2.11. Only authorised persons have access to personnel records.
2.6. Quality improvement

2.6.1. A formalised proactive quality improvement approach is maintained in the
service.

Intent of 2.6.1
It is the responsibility of the management of the organisation to ensure that standards are set
throughout the organisation. Within each department or service, it is the responsibility of managers to
ensure that standards are set for the particular department. This requires co-ordination with the
organisation's quality improvement steering committee. Departmental managers use available data
and information to identify priority areas, which urgently require quality monitoring and improvement.
2.6.1 Criteria
2.6.1.1. Indicators of performance are identified to evaluate the quality of the service.
2.6.1.2. Processes related to service provision are selected in order of priority for evaluation and
improvement.
2.6.1.3. There is a relevant monitoring system for the standards of the service.
2.6.1.4. Data are available to demonstrate that improvements are sustained.


3.Administrative Support
Overview of Administrative Support

The administrative support service provides the organisation with effective structures to support
patient care. The organisation's leaders need to be able to rely on an effective and efficient
administrative support system for the planning, organisation and co-ordination of managerial
processes. Persons responsible for providing administrative support services must be suitably trained
and experienced in, e.g. financial management, human resource management, and in providing
equipment and supplies.
The administrative service is frequently the window to the public, i.e. admission and discharge
systems, and sending and collecting accounts.
The administrative support system ensures an effective filing and storage system for records,
including financial and staff records.
Administrative staff use quality improvement methods to improve the administrative support structures.

Standards
3.1. Financial management support

3.1.1. Budgeting, reporting and auditing processes are consistent with statutory
requirements and accepted standards.
Intent of 3.1.1
Financial planning and management needs to be conducted by a person who is suitably qualified and
experienced in all matters relating to the organisation's finances. Clinical and other leaders need to be
included in planning their financial requirements. They also require information relating to the funds
available to them for the management of their departments, and up-to-date statements of current
expenditure. Sound accounting and auditing practices are implemented to ensure transparency.
Financial managers improve their services through quality improvement methods.
3.1.1 Criteria
3.1.1.1. A designated financial manager is responsible for the implementation and maintenance of the
financial strategy.
3.1.1.2. The financial manager is suitably qualified and experienced in financial management.
3.1.1.3. The financial manager ensures that policies and procedures are available to guide the staff and that
they are implemented.
3.1.1.4. There are written policies and procedures for accounting functions.
3.1.1.5. There are written policies and procedures for maintaining an internal financial audit system which
meets audit requirements.
3.1.1.6. There are written policies and procedures for the payment of creditors.
3.1.1.7. There is a mechanism for developing budgets (e.g. cost centres) with the participation of the staff.
3.1.1.8. There are systems to ensure that financial resources available for the HIV/AIDS programme are
accessed and utilized optimally.
3.1.1.9. A report is produced monthly for the organisation’s management, setting out the financial position to
date.
3.1.1.10. There is a mechanism for establishing the reason for budget variation in either income or expenditure.
3.1.1.11. Annual financial statements are produced within three months of the end of the financial year.
3.1.1.12. There is a capital asset register, which is routinely maintained.
3.1.1.13. There is a capital asset replacement programme.
3.1.1.14. Capital investment proposals are subject to evaluation by a committee.
3.1.1.15. There is a mechanism to ensure that the level of debtors is kept to a minimum.
3.2. Procurement and supplies

3.2.1. There is a system to ensure that equipment and supplies are ordered,
available, stored and distributed from a central point.
Intent of 3.2.1
A competent and qualified person ensures the effective administration of the provisioning department.
This includes the timeous ordering of equipment and supplies, safe storage, prevention and notification
of losses, effective distribution to departments on request, and maintenance of information relating to
ordering, receipt, storage and distribution of equipment and supplies. Managers need to be assured
that all equipment and supplies needed by departments will be immediately available on request.
Policies and procedures guide the processes of provisioning management.
The organisation's leaders need to ensure that finances are made available for the purchase of those
items of equipment and supplies which have been identified as needed by clinical and managerial
leaders. The provisioning managers therefore need to work closely with the financial manager.

3.2.1 Criteria
3.2.1.1. An individual is designated to control the ordering, storage, distribution and control of equipment and
supplies used in the organisation.
3.2.1.2. The supplies manager is suitably qualified and experienced in provisioning management.
3.2.1.3. The supplies manager ensures that policies and procedures are available to guide the staff and that
they are implemented.
3.2.1.4. Policies and procedures guide the ordering of supplies and equipment.
3.2.1.5. Policies and procedures guide the payment for supplies and equipment received.
3.2.1.6. Policies and procedures guide the safe storage of supplies and equipment.
3.2.1.7. Policies and procedures guide the issuing of supplies and equipment.
3.2.1.8. Policies and procedures guide the condemning of equipment.
3.2.1.9. Policies and procedures guide the security of order books, prescription pads, and other face-value
documents.
3.2.1.10. The administrative support service provides the HIV/AIDS manager with effective structures to
support the HIV/AIDS programme.
3.2.2. There is an information system that collects, collates and analyses information
relating to the receipt and distribution of equipment and supplies.
Intent of 3.2.2
The high costs of hospital supplies and equipment make it essential that sound auditing practices are
in place to ensure control of the financial aspects of provisioning. A management information system
must track all inventory. Expenditure on equipment and supplies is transparent, and all records must
be monitored and available to managers and auditors for accounting.
3.2.2 Criteria
3.2.2.1. A record is kept of goods received and goods issued.
3.2.2.2. Records are audited.
3.2.2.3. All losses are investigated, reported and recorded.
3.2.2.4. There is an inventory of all goods stored.
3.2.3. All equipment and supplies are safely stored.

Intent of 3.2.3
The storage of equipment and supplies must allow for security, ease of access, and effective inventory
taking. Acts and regulations, as well as policies and procedures, guide the storage of equipment and
supplies.
The administrative support service ensures that supplies and provisions are ordered, received and
timeously provided to departments to meet their needs.
3.2.3 Criteria
3.2.3.1. Secure storage facilities are available.
3.2.3.2. Hazardous and flammable materials are stored in accordance with relevant regulations.
3.2.3.3. Separate designated storage areas for the receipt and unpacking of incoming goods are provided.
3.2.3.4. Arrangements, including alarm systems and door access controls, are used to provide security.
3.2.3.5. There is adequate storage space to enable rapid retrieval and removal of equipment when needed.
3.3. Use of motor vehicles

3.3.1. The use of organisational motor vehicles by staff is planned and monitored to
ensure safety and legality.

Intent of 3.3.1
The use of vehicles needs to be controlled because of the cost of acquiring and maintaining vehicles,
and legal aspects relating to the driving of vehicles and transport of passengers.
3.3.1 Criteria
3.3.1.1. A specific manager is identified for the control, use and maintenance of vehicles.
3.3.1.2. The need for the use of transport is established by the management of the organisation in
consultation with the users of vehicles and is reviewed annually.
3.3.1.3. There is a system for monitoring the use of vehicles (e.g. permission, records).
3.3.1.4. There is a system for the booking of vehicles in advance.
3.3.1.5. There is a control system for mileage travelled.
3.3.1.6. There is a vehicle maintenance programme.
3.3.1.7. There is proof of vehicle maintenance.
3.3.1.8. Drivers of vehicles are suitably licensed.
3.3.1.9. The organisation has a documented, current, accurate inspection of its transport and other vehicles.
3.3.1.10. The organisation implements processes to reduce evident risks based on the inspection.
3.3.2. The organisation provides an ambulance service in line with government

regulations.
Intent of 3.3.2
A comprehensive response and deployment plan addresses location of facilities and distribution of
vehicles, staff and other resources. These should be deployed in a way that optimises their utilitisation
and provides uniform care across the area served.
3.3.2 Criteria
3.3.2.1. The organisation has a written response and deployment plan including the identification of response
areas and availability of response units.
3.3.2.2. The organisation designs and implements processes to provide coordination of services among other
organisations and agencies in the community.
3.3.2.3. The plan includes coverage of peak periods.
3.3.2.4. The plan includes response to multiple-victim incidents.
3.3.2.5. The plan includes disaster response.
3.3.2.6. The organisation has a prioritisation process for medical transport requests.
3.3.2.7. The prioritisation process uses written guidelines that determine both response level and urgency.
3.3.2.8. The response time standards meet national laws, regulations, policies or guidelines.
3.3.3. The training and experience required of ambulance personnel is specified.

3.3.3 Criteria
3.3.3.1. A determination is made about the required qualifications of the individual to provide ambulance
services.
3.3.3.2. Staff are trained to operate and maintain medical equipment.
3.3.3.3. An inventory of equipment and supplies is checked daily or after use.
3.3.3.4. Staff are trained to operate and maintain communication equipment.
3.3.3.5. Staff are trained in the maintenance of transport vehicles.
3.3.3.6. Staff are trained in vehicle operating safety, including staff and patient use of seat belts.
3.3.3.7. Staff are trained regarding conditions that warrant the violation of existing traffic laws.
3.3.4. Ambulances are clean and in working order when in use.

3.3.4 Criteria
3.3.4.1. Policies and procedures include the sites at which vehicles may be cleaned.
3.3.4.2. Polices and procedures specify what cleaning methods and chemicals must be used for cleaning
vehicles.
3.3.4.3. Policies and procedures address waste management issues.
3.3.4.4. Policies and procedures address the prevention of environmental pollution by cleaning chemicals and
clinical/healthcare waste.
3.3.4.5. Policies and procedures address the training of personnel in proper cleaning methods.


4.Access to Care
Overview of Access to Care

A healthcare organisation should consider the care it provides as part of an integrated system of
services, healthcare professionals, and levels of care, which make up a continuum of care. The goal
is to correctly match the patient's healthcare needs to the services available. Only those patients, for
whom the organisation can be expected to provide care, enter the organisation.
In order to meet the community's needs for services, the organisation needs to clearly define the
boundaries of the community, and the boundaries of the services provided by the organisation, and to
involve the community in the planning for care. The community needs to be provided with information
relating to the services offered by the organisation, the hours at which services are offered, and how to
obtain access to care.
The leaders of the organisation ensure equitability of service provision through community
participation.

Standards
4.1. Selection of patients for the provision of care

4.1.1. Patients have access to the healthcare organisation’s services, based on their
identified healthcare needs and the organisation’s mission and resources.
Intent of 4.1.1
To improve access to its services, the healthcare organisation provides information to the community
on its services and hours of operation and how to obtain care.
Only those patients for whom the organisation can be expected to provide care enter the organisation.
Matching patient needs to the healthcare organisation's mission and resources depends on obtaining
information on the patient's needs and condition through screening at the first point of contact. The
screening can occur at the referral setting, during emergency transport, or when the patient arrives at
the organisation.
The screening assessment leads to an understanding of the type of preventive, palliative, curative and
rehabilitative services needed by the patient. This information is used to determine the most
appropriate setting(s) required to meet the patient's most urgent needs. Thus, admission to the
organisation and/or referral to another setting may be required to meet the patient's needs.
The patient's needs may have been determined before entering the organisation by a physician or
other organisation. If the patient's needs had not been determined prior to entry, those needs are
identified through a triage process, screening assessment, or medical history and physical examination
of the patient. Diagnostic testing may also be required to:
• determine the patient's needs;
• determine if the organisation has the appropriate resources to treat the patient, or
• establish if the patient should be referred or transferred to another setting for care.
For emergency or critical patients, the needs are clear and diagnostic testing follows admission.
Diagnostic test results are made available to those who must decide on further management in the
facility, transfer or referral of the patient.
4.1.1 Criteria
4.1.1.1. Information on services, hours of operation, and processes to obtain care are provided to agencies
and referral sources in the community, and to the population served.
4.1.1.2. Screening is initiated at the point of first clinical contact.
4.1.1.3. The screening assessment leads to an understanding of the type of preventive, palliative, curative
and rehabilitative services needed by the patient.
4.1.1.4. If the organisation does not have the ability to provide the necessary services and settings for care,
the patient is referred.
4.1.1.5. The suitability of the patient for admission is based on the results of the screening, in accordance with
the mission and resources of the organisation.
4.2. Admission processes

4.2.1. There is an established process for admitting patients to the organisation.
Intent of 4.2.1

The process for admitting patients to the organisation for care is standardised through the use of
polices and procedures. The staff responsible for the admission process are familiar with and follow
the standardised procedures. The policies and procedures address the admission of patients directly
from the emergency service and the process for holding patients for observation. The policies also
address how patients are managed when inpatient facilities are limited or no space is available to
admit patients.
Patients with emergency or immediate needs are assessed and receive care as quickly as necessary
and possible. Such patients may be assessed by the physician before other patients, receive
diagnostic services and have treatment initiated to meet their needs as rapidly as possible. The
organisation establishes criteria and trains the staff to recognise those patients with immediate needs
and prioritise their care process.
4.2.1 Criteria
4.2.1.1. There is a process, known to the staff, for admitting patients to the organisation.
4.2.1.2. Policies and procedures are used to standardise the admitting process.
4.2.1.3. The staff are familiar with the policies and procedures and follow them.
4.2.1.4. The policies and procedures address the admission of emergency patients.
4.2.1.5. The organisation has established criteria to prioritise patients with immediate needs.
4.2.1.6. Patients with emergency or immediate needs are prioritised for assessment and intervention.
4.2.1.7. The staff are trained to use the criteria for prioritising the needs of emergency patients.
4.2.1.8. Policies and procedures address the holding of patients for observation.
4.2.1.9. Policies and procedures address the management of patients when bed space is not available in the
desired service or unit or elsewhere in the facility.
4.2.2. During the entry process, patients and their families receive sufficient
information to make informed decisions.
Intent of 4.2.2
During the entry process, patients and their families receive sufficient information to make an informed
decision about seeking care. Information is provided on what care is proposed, the expected results,
and any expected cost to the patient or family for that care, when this is not paid for by a public or
private source. Patients and families need complete information on the care and services offered by
the organisation, as well as on how to access those services. Providing this information is essential to
the building of an open and trusting communication between patients, families and the organisation.
This information helps to match the patient's expectations to the ability of the organisation to meet
those expectations. Information on alternative sources of care and services is provided, when the
needed care is beyond the organisation's mission and capabilities.
For patients and families to participate in care decisions, they need basic information regarding the
medical conditions, found during assessment and on the care and treatment proposed. Patients and
families understand when they will be given this information and who is responsible for telling them.
Patients and families understand the type of decisions that must be made about care and how to
participate in those decisions. In addition, patients and families need to understand the organisation's
process to obtain consent and which care processes, tests, procedures and treatments require their
consent.
While some patients may not wish to personally participate in the decisions regarding their care, they
are, nevertheless, given the opportunity, and can choose to participate through a family member,
friend or a surrogate decision-maker.

4.2.2 Criteria
4.2.2.1. Patients are given information about the facilities and services provided by the organisation at the
time of first contact with the service.
4.2.2.2. Patients receive sufficient information to make informed decisions.
4.2.2.3. Information on the proposed care and the expected results of care are provided.
4.2.2.4. Information on any expected costs to the patient is provided.
4.2.2.5. Patients are given information on how to access services in the organisation.
4.2.2.6. Information on alternative sources of care and services is provided when the organisation cannot
provide the care or services required.
4.2.2.7. Patients and families understand how and when they will be told of medical conditions.
4.2.2.8. Patients and families understand how and when they will be told of planned treatments.
4.2.2.9. Patients and families understand the process used to obtain consent.
4.2.2.10. The information is provided to families, as appropriate.
4.2.2.11. Information is provided in a way and in a language understood by those making the care decisions.
4.2.3. The organisation seeks to reduce physical, language, cultural and other
barriers to access and delivery of services.
Intent of 4.2.3
Organisations frequently serve communities with a diverse population. Patients may be aged, have
disabilities, speak multiple languages or dialects, be culturally diverse, or present other barriers that
make the process of entering the organisation and receiving care very difficult. The organisation is
familiar with these barriers and has implemented processes to eliminate or reduce these barriers
during the entry process. For instance, wheelchairs will be available for the physically disabled, the
staff will be trained to communicate with the hard of hearing, and translation services will be available
for those who speak foreign languages. Mechanisms for meeting these needs will be documented and
known to the staff.
4.2.3 Criteria
4.2.3.1. The organisation has identified the barriers in its patient population.
4.2.3.2. There is a process to overcome or limit barriers during the entry process.
4.2.3.3. There is a process to limit the impact of barriers on the delivery of services.
4.2.3.4. These processes are implemented.
4.2.4. Entry or transfer to units providing intensive or specialised services is

determined by established criteria.
Intent of 4.2.4
Units or services that provide intensive care (for example a post-surgical intensive care unit) or that
provide specialised services (for example the care of patients with burns, or organ transplant units),
are costly and usually have limited space and staff. Each organisation must establish criteria for
identifying those patients who require the level of care provided in such units. Appropriate individuals
from the intensive or specialised services participate in developing those criteria. The criteria are
used to determine direct entry to the unit, for example directly from the emergency service.
The criteria are also used to authorise transfer into the unit from within or outside the organisation, and
in deciding when a patient no longer requires the services of the unit and can be transferred to another
level of care.

4.2.4 Criteria
4.2.4.1. The organisation has established entry and/or transfer criteria for its intensive and specialised
services.
4.2.4.2. Appropriate individuals are involved in developing the criteria.
4.2.4.3. The staff are trained to apply the criteria.
4.2.4.4. Patients transferred or admitted to intensive and specialised units/services meet the criteria.
4.2.4.5. Patients who no longer meet the criteria are transferred or discharged.
4.2.5. Established protocols or criteria determine admission or transfer to research

and other programmes designed to meet special patient needs.
Intent of 4.2.5
When the organisation conducts research programmes, admission or transfer into such programmes
are through established criteria or protocols. Appropriate individuals from the research or other
programmes are involved in developing the criteria or protocols. Admission to such programmes is
documented in the patent's record. The criteria or protocol conditions, under which the patient was
admitted or transferred, are also recorded.
4.2.5 Criteria
4.2.5.1. The organisation has criteria or protocols for entry into research or other programmes, to meet special
needs, when available in the organisation.
4.2.5.2. Appropriate individuals participate in developing the criteria or protocols.
4.2.5.3. The staff are trained to apply the criteria or protocols.
4.2.5.4. Documentation in patient records identifies the criteria or protocol conditions met when entry occurs.
4.2.5.5. Patients admitted to research programmes meet the criteria.


5.Patient and Family Rights
Overview of Patient and Family Rights

Each patient is unique, with his or her own needs, strengths, values and beliefs. Healthcare
organisations work to establish trust and open communication with patients and to understand and
protect each patient's cultural, psychosocial and spiritual values.
Patient care outcomes are improved when patients, and, as appropriate, their families or those who
make decisions on their behalf, are involved in care decisions and processes in a way that matches
cultural expectations.
To promote patient rights in a healthcare organisation, one starts by defining those rights, followed by
educating patients and the staff about those rights. Patients are informed of their rights and how to
act on them. The staff are taught to understand and respect patients' beliefs and values and to provide
considerate and respectful care, thus protecting the patients' dignity.
This chapter addresses processes to:

• identify, protect and promote patient rights;
• inform patients of their rights;
• include the patient's family, when appropriate, in decisions about the patient's care;
• obtain informed consent;
• educate the staff about patient rights; and
• guide the organisation's ethical framework.
How these processes are carried out in an organisation depends on its country's laws, regulations and
charters and any international conventions, treaties or agreements on human rights, endorsed by that
country.
The implementation of patient rights is dependent on the healthcare organisation providing equitable
services.

Standards
5.1. Implementation of patient rights

5.1.1. The organisation is responsible for providing processes that support patient
and family rights during care.
Intent of 5.1.1
An organisation's leaders are primarily responsible for the way in which that organisation treats its
patients. The leaders need to know and understand patient and family rights and their organisation's
responsibilities as specified in laws, charters and regulations. The leaders then provide direction to
ensure that the staff throughout the organisation assume responsibility for protecting these rights. To
effectively protect and advance patient rights, the leaders work collaboratively, and seek to understand
their responsibilities in relation to the community served by the organisation.
Patient and family rights are a fundamental element of all contacts between the staff of an organisation
and patients and families. Thus, policies and procedures are developed and implemented to ensure
that all staff are aware of and respond to patient and family rights issues, including their role in
supporting patients' and families' rights to participate in the care process.
Admission to a healthcare organisation can be a frightening and confusing experience for patients,
making it difficult for them to understand and act on their rights. Thus, the organisation prepares a
written statement of patient and family rights, and this is given to patients when they enter the
organisation for care, and is available throughout their stay. For example, the statement may be
posted in the facility.
The statement is appropriate to the patient's age, understanding and language. When written
communication is not effective or appropriate, the patient and family are informed of their rights in a
manner they can understand.
5.1.1 Criteria
5.1.1.1. The leaders of the organisation work collaboratively to protect and advance patient and family rights
through an established framework.
5.1.1.2. Patient and family rights are identified and documented in accordance with relevant and current laws,
charters and regulations.
5.1.1.3. Policies and procedures guide and support patient and family rights in the organisation.
5.1.1.4. Policies and procedures are developed to support and promote patient and family participation in care
processes.
5.1.1.5. The staff are trained on the policies and procedures and their participative role in care processes.
5.1.1.6. Each patient is given information about his/her rights in a language that he or she can understand.
5.1.1.7. The organisation has a process to inform patients of their rights when written communication is
neither effective nor appropriate.
5.1.1.8. The organisation has a process to inform patients and families about its care and services and how to
access those services.
5.1.1.9. There is a mechanism to ensure that patient and family rights are implemented.
5.2. Respect for patient values and beliefs

5.2.1. Processes ensure that care is considerate and respectful of the patient’s
personal values and beliefs.
Intent of 5.2.1
Each patient brings his or her own set of values and beliefs to the care process. Some values and
beliefs are commonly held by all patients and are frequently cultural and religious in origin. Other

values and beliefs are those of the patient alone. All patients are encouraged to express their beliefs
in ways that respect the beliefs of others.
Strongly held values and beliefs can shape the care process and how patients respond to care.
Thus, each care provider seeks to understand the care and services they provide within the context of
the patient's values and beliefs. The organisation educates all staff about the rights of patients and
families. The educational process recognises that staff members may hold values and beliefs that are
different from the patients under their care. The educational process includes training each staff
member how to identify patient values and beliefs, and how to respect those values and beliefs in the
care process. Patients and families participate in the care process by making decisions about care,
asking questions about care, and even refusing care. The organisation supports and promotes this
patient and family involvement in all aspects of care through the development and implementation of
related policies and procedures. The organisation uses a collaborative and inclusive process to
develop the policies and procedures, and, when appropriate, includes patients and families.
Compassionate care includes providing the patient with adequate information on which to make
decisions, adequate relief of pain, and consideration of the needs of the dying.
5.2.1 Criteria
5.2.1.1. There is a process to identify and respect patient values and beliefs.
5.2.1.2. The staff uses the process to provide care that is respectful of the patient’s values and beliefs.
5.2.1.3. The organisation educates the staff about the values and beliefs of patients.
5.2.1.4. The patient’s right to adequate information, on which to make decisions, is protected.
5.3. Protection of privacy, person and possessions

5.3.1. The organisation takes measures to protect patient privacy.
Intent of 5.3.1
The organisation ensures that the patient's needs for privacy are respected, especially when the
patient is providing personal information and undergoing clinical examination. Patients may desire
privacy from other staff, other patients, and even from family members.
Medical and other health information, when documented and collected in a patient record or other
form, is important for understanding the patient, his or her needs, and for providing care and services
over time. The organisation respects such information as confidential, and has implemented policies
and procedures that protect such information from loss or misuse. The staff respects the
confidentiality of patient information by not posting information on the patient's door or at the nursing
station and by not holding patient-related discussions in public places. The misuse of patient
information can result in the patient's loss of dignity, employment, and damage to personal or family
relationships. Misuse can be by the staff of the organisation, family members, or others not authorised
to have access to the information.
When the organisation takes responsibility for any or all of the patient's personal possessions brought
into the organisation, there is a process to account for those possessions and ensure that they will not
be lost or stolen. This process considers the possessions of emergency patients, those patients
unable to make alternative safekeeping arrangements and those incapable of making decisions
regarding their possessions. The organisation communicates its responsibility, if any, for the patient's
possessions to patients and families.

5.3.1 Criteria
5.3.1.1. The patient’s need for privacy is protected during all examinations, procedures and treatments.
5.3.1.2. The patient’s need for privacy is protected when providing personal information.
5.3.1.3. The organisation respects patient health information as confidential.
5.3.1.4. Policies and procedures to prevent the loss and/or misuse of patient information are implemented.
5.3.1.5. The organisation has determined its level of responsibility for patients’ possessions.
5.3.1.6. Patients receive information about the organisation’s responsibility for protecting personal belongings.
5.3.1.7. Patients’ possessions are safeguarded when the organisation assumes responsibility or when the
patient is unable to assume responsibility.
5.3.2. Patients are protected from physical assault.

Intent of 5.3.2
The organisation takes responsibility for protecting patients from physical assault by outsiders, other
patients and the staff. This responsibility is particularly relevant to infants and vulnerable children, the
elderly, and others unable to protect themselves or signal for help. Each organisation identifies its
vulnerable patient groups and establishes a process to protect the rights of individuals in those groups.
Vulnerable patient groups and the organisation's responsibility may be identified in laws, charters or
regulations. Comatose patients, and patients with mental or emotional disabilities, are also included.
Such protection extends beyond physical assault to other areas of safety such as protection from
abuse, negligent care, withholding of services, or assistance in the event of a fire.
The organisation seeks to prevent assault through processes such as investigating individuals in the
facility without identification, monitoring remote or isolated areas of the facility, and quickly responding
to those thought to be in danger of assault.
The staff understands their responsibilities in these processes.
5.3.2 Criteria
5.3.2.1. The organisation has a process to protect patients from assault.
5.3.2.2. Vulnerable children, disabled individuals, the elderly, and others identified by the organisation are
protected.
5.3.2.3. Individuals entering the organisation without identification are investigated.
5.3.2.4. Remote or isolated areas of the hospital are monitored.
5.3.2.5. The staff understands their responsibilities in the protection processes.
5.4. Right to health education

5.4.1. Health education supports patient and family participation in care decisions
and care processes.
Intent of 5.4.1
Every patient is offered the information and education he or she requires. Organisations may choose
to appoint an education co-ordinator, an education committee, or service, or simply work with all staff
to provide education in a co-ordinated manner.
5.4.1 Criteria
5.4.1.1. The organisation plans education consistent with its mission, services and patient population.
5.4.1.2. There is an appropriate structure or mechanism for education throughout the organisation.
5.4.1.3. Educational resources are organised in an efficient and effective manner.

5.5. Right to treatment and to refuse treatment

5.5.1. The organisation respects the rights of patients and families to refuse or
discontinue treatment.
Intent of 5.5.1
Patients, or those making decisions on their behalf, may decide not to proceed with the planned care
or treatment or to continue care or treatment after it has been initiated. The organisation informs
patients and families about their right to make these decisions, about the potential outcomes that could
result from these decisions, and about their responsibilities related to such decisions. Patients and
families are given information on any care and treatment alternatives. Staff are informed of their
responsibility to implement and respect the choices of patients.
5.5.1 Criteria
5.5.1.1. Patients and families are informed about their rights to refuse or discontinue treatment.
5.5.1.2. Patients are informed about the consequences of such decisions.
5.5.1.3. Patients and families are informed about their responsibilities related to such decisions.
5.5.1.4. The organisation ensures that the patient’s declared choices are implemented and respected.
5.5.1.5. Patients are informed about available care and treatment alternatives.
5.5.2. The organisation respects patients’ wishes and preferences to withhold

resuscitative services and forgo or withdraw life-sustaining treatment.
Intent of 5.5.2
Decisions about withholding resuscitative services or forgoing or withdrawing life-sustaining treatment
are among the most difficult choices facing patients, families, healthcare professionals and
organisations. No single process can anticipate all the situations in which such decisions must be
made. For this reason, it is important for the organisation to develop a framework for making these
difficult decisions.
Such a framework:
• helps the organisation identify its position on these issues;
• ensures that the organisation's position conforms to its community's religious and cultural norms
and to any legal or regulatory requirements;
• addresses situations in which these decisions are modified during care; and
• guides health professionals through the ethical and legal issues in carrying out such patient
wishes.
To ensure that the decision-making process related to carrying out the patient's wishes is applied
consistently, policies and procedures are developed through a process that includes many
professionals and various viewpoints. The policies and procedures identify lines of accountability and
responsibility and how the process is documented in the patient's record.
5.5.2 Criteria
5.5.2.1. The organisation has identified its position on withholding resuscitative services and forgoing or
withdrawing life-sustaining treatments.
5.5.2.2. The organisation’s position conforms to its community’s religious and cultural norms and to any legal
or regulatory requirements.
5.5.2.3. Policies and procedures guide the processes for patients to make their decisions known to the
organisation and for modifying decisions during the course of care.

5.5.2.4. Policies and procedures guide the organisation’s response to patient decisions.
5.5.2.5. The policies and procedures were developed through a collaborative and inclusive process.
5.5.2.6. Documentation about decisions follows organisational policy.
5.5.2.7. The organisation guides health professionals on the ethical and legal issues in carrying out such
patient wishes.
5.5.2.8. Patient decisions are respected.
5.6. Human tissue donation or participation in research

5.6.1. The organisation informs patients and families about how to choose to donate
organs and other tissues.
Intent of 5.6.1
The organisation supports the choice of patients and families to donate organs and other tissues for
research or transplantation. Information is provided on the donation process and, if the organisation is
a procurement site, policies and procedures are developed to guide the procurement and donation
process if applicable. The policies are consistent with laws and regulations and respect the
community's religious and cultural values. Organisational staff are trained in implementing the policies
and procedures to support patient and family choices. The organisation co-operates with other
organisations and agencies in the community responsible for all or a portion of the procurement,
banking, transportation, or transplantation process.
5.6.1 Criteria
5.6.1.1. The organisation supports patient and family choices to donate organs and other tissues.
5.6.1.2. The organisation provides information to support the choice.
5.6.1.3. Policies and procedures guide the procurement and donation process.
5.6.1.4. Staff are trained in the policies and procedures.
5.6.1.5. The organisation co-operates with relevant organisations and agencies in the community to respect
and implement choices to donate.
5.6.2. The organisation informs patients and families about how to gain access to
clinical research, investigations, or clinical trials involving human subjects.
Intent of 5.6.2
An organisation that conducts research, investigations, or clinical trials involving human subjects
knows that its first responsibility is to the patient's health and well-being. It provides information to
patients and families about how to gain access to those activities when relevant to the patient's
treatment needs. When patients are asked to participate, they need information on which to base
their decision. That information includes a description of:
• expected benefits;
• potential discomforts and risks;
• alternatives that might also help them; and
• procedures that must be followed.
Patients are informed that they can refuse to participate or can withdraw from participation, and that
their refusal or withdrawal will not compromise their access to the organisation's services.
The organisation has policies and procedures for providing patients and families with this information.
The organisation informs patients and families in advance about established processes to:
• review research protocols;

• weigh the relative risks and benefits to the patient;

• obtain patient consent; and
• withdraw from participation.
This information is communicated to patients and families to assist with decisions regarding
participation.
5.6.2 Criteria
5.6.2.1. Policies and procedures guide the information and decision process for involving patients in clinical
research.
5.6.2.2. Patients and families are given information about how to gain access to any research, investigations,
or clinical trials relevant to their treatment needs.
5.6.2.3. The organisation informs patients and families about how patients who choose to participate in
research, investigations or clinical trials are protected.
5.6.2.4. Informed consent is obtained before a patient participates in clinical research, investigations or trials.
5.6.2.5. Patients asked to participate are given information on expected benefits.
5.6.2.6. Patients asked to participate are given information on potential discomforts and risks.
5.6.2.7. Patients asked to participate are given information on alternatives that might also help them.
5.6.2.8. Patients asked to participate are given information on the procedures that must be followed.
5.6.2.9. Patients asked to participate are given information on the process, used by the organisation, to review
research protocols.
5.6.2.10. Patients asked to participate are given information on the process, used by the organisation, to weigh
the benefits and risks to the subjects.
5.6.2.11. Patients asked to participate are given information on the process, used by the organisation, to obtain
consent.
5.6.2.12. Patients asked to participate are given information on
the process, used by the organisation, to withdraw from participation.
5.6.2.13. Patients are assured, that their refusal to participate, or their withdrawal from participation, will not
compromise their access to the organisation’s services.
5.7. Right to voice complaints

5.7.1. The organisation informs patients and families about its process to receive and
act on complaints, conflicts and differences of opinion about patient care, and the
patient’s right to participate in these processes.
Intent of 5.7.1
Patients have a right to voice complaints about their care, and to have those complaints reviewed and,
where possible, resolved. Also, decisions regarding care sometimes present questions, conflicts or
other dilemmas for the organisation and the patient, family or other decision-makers. These dilemmas
may arise around issues of access, treatment or discharge. They can be especially difficult to resolve
when the issue involves, for example, withholding resuscitative services or forgoing or withdrawing life-
sustaining treatment.
The organisation has established processes for seeking resolutions to such dilemmas and complaints.
The organisation identifies in policies and procedures those who need to be involved in the processes
and how the patient and family participate.
5.7.1 Criteria
5.7.1.1. There is a mechanism to allow for the hearing of complaints and to act upon them.
5.7.1.2. Policies and procedures identify participants in the process and include family members.
5.7.1.3. Patients are aware of their right to voice complaints and the processes by which to do so.
5.7.1.4. Complaints are reviewed according to the organisation’s mechanism.

5.8. Informed consent

5.8.1. The organisation has a clearly defined process for obtaining consent.
Intent of 5.8.1
One of the main ways that patients are involved in their care decisions is by granting informed
consent. The patient must be provided with all information relating to the planned care to enable him
or her to make decisions. The consent process is clearly defined by the organisation in policies and
procedures. Relevant laws and regulations are incorporated into the policies and procedures.
Informed consent for care sometimes requires that people other than (or in addition to) the patient be
involved in decisions about the patient's care. This is especially true when the patient does not have
the mental or physical capacity to make care decisions, when culture or custom designate that others
make care decisions, or when the patient is a child. When the patient cannot make decisions
regarding his or her care, a surrogate decision-maker is identified. When someone other than the
patient gives the consent, that individual is noted in the patient's record.
5.8.1 Criteria
5.8.1.1. Policies and procedures guide the staff in the process of gaining informed consent.
5.8.1.2. The process respects laws, culture and custom.
5.8.1.3. Those persons who may obtain informed consent are identified.
5.8.1.4. The organisation has a procedure, which is implemented, when others have to grant informed
consent.
5.8.1.5. A note is made in the patient’s record when any individual, other than the patient, grants consent.
5.8.1.6. Patients give informed consent in accordance with the appropriate policies and procedures.
5.8.2. The organisation has listed those situations that require consent.
Intent of 5.8.2
Informed consent may be obtained at several points in the care process. For example, informed
consent can be obtained before the patient enters the organisation or before certain high-risk
procedures or treatments. General consent for treatment is obtained when the patient enters the
organisation. Patients are given information on the scope of the general consent, and which diagnostic
and other tests are included therein.
When the planned care includes surgical or invasive procedures, anaesthesia, the use of blood or
blood products, or other high-risk treatments or procedures, a separate consent is obtained.
However, not all treatments and procedures require a specific, separate consent. Each organisation
identifies those high-risk, problem-prone or other procedures and treatments for which consent must
be obtained. The organisation lists these procedures and treatments and educates the staff to ensure
that the process to obtain consent is consistent. Those who provide the treatments or perform the
procedures develop the list collaboratively.
This consent process provides the information identified, and documents the identity of the individual
providing the information. When patients and families decide to participate in clinical research,
investigations, or clinical trials, informed consent is obtained.
5.8.2 Criteria
5.8.2.1. General consent / acknowledgement of admission requirements is obtained when patients enter the
organisation.
5.8.2.2. Patients and families acknowledge the scope of such general consent / admission requirements.

5.8.2.3. High-risk and problem-prone procedures are identified and listed as requiring special consent.
5.8.2.4. Written consent is to be obtained before surgical or other invasive procedures.
5.8.2.5. Written consent is to be obtained before anaesthesia.
5.8.2.6. Written consent is to be obtained before blood or blood products are administered.
5.8.2.7. Written consent is to be obtained when a patient decides to participate in clinical research,
investigations, or trials.


6.Management of Information
Overview of Management of Information

Providing patient care is a complex endeavour that is highly dependent on information. To provide,
co-ordinate, and integrate services, healthcare organisations rely on information about the science of
care, individual patients, care provided, results of care, and their own performance. Just like human,
material and financial resources, information is a resource that must be managed effectively by the
organisation's leaders. Every organisation seeks to obtain, manage and use information to improve
patient outcomes and individual and overall organisational performances.
Over time, organisations become more effective in:

• identifying information needs;
• designing an information management system;
• defining and capturing data and information;
• analysing data and transforming them into information;
• transmitting and reporting data and information; and
• integrating and using information.
Although computerisation and other technologies improve efficiency, the principles of good information
management apply to all methods, whether paper-based or electronic.

Standards
6.1. Planning
6.1.1. The organisation plans and implements processes to meet the information
needs of clinical and managerial services, and those outside the organisation that
require data and information from the organisation.
Intent of 6.1.1
Information is generated and used during patient care and for safely and effectively managing an
organisation. The ability to capture and provide information requires effective planning. Planning
incorporates input from a variety of sources:
• the care providers;
• the organisation's managers and leaders; and
• those outside the organisation who need or require data or information about the organisation's
operational and care processes.
The most urgent information needs of those sources influence the organisation's information
management strategies and it's ability to implement those strategies. The strategies are appropriate
for the organisation's size, complexity of services, availability of trained staff and other human and
technical resources. The plan is comprehensive and includes all the departments and services of the
organisation.
6.1.1 Criteria
6.1.1.1. An information plan is developed and implemented in the organisation.
6.1.1.2. Those who provide clinical and managerial services identify their information needs.
6.1.1.3. Identified information needs are included in the plan.
6.1.1.4. Clinical and managerial staff participate in information technology decisions.
6.1.1.5. Strategies are implemented to meet the information needs of individuals and agencies outside the
organisation.
6.1.1.6. The information plan is appropriate to the size, complexity and purpose of the organisation.
6.1.2. Confidentiality, security and integrity of data and information is maintained.

Intent of 6.1.2
The organisation determines the level of security and confidentiality to be maintained for different
categories of information. Access to each category of information is based on need and defined by job
title and function. An effective process defines:
• who has access to information;
• the information to which an individual has access;
• the user's obligation to keep information confidential, and
• the process followed when confidentiality and security are violated.
One aspect of maintaining security of patient information is to determine who is authorised to obtain a
patient record and who makes entries into the patient record. The organisation develops a policy to
authorise such individuals and identifies the contents and format for entries into patient records. There
is a process to ensure that only authorised individuals make entries in patient records.
The organisation maintains the security and confidentiality of data and information, and is especially
careful about preserving the confidentially of sensitive data and information. The balance between
data sharing and data confidentiality is addressed.

6.1.2 Criteria
6.1.2.1. The plan includes how confidentiality of data and information will be maintained.
6.1.2.2. The plan includes how the security and integrity of data and information will be maintained.
6.1.2.3. The plan identifies those permitted access to each category of data and information.
6.1.2.4. The format and location of entries are determined by the organisation’s management.
6.1.2.5. There is a process to ensure that only authorised individuals make entries in patient records.
6.1.3. The information plan is implemented and supported by sufficient staff and
other resources.
Intent of 6.1.3
The organisation's information management plan, once complete and approved as necessary, is
implemented. The organisation provides the staff, technology and other resources necessary to
implement the plan and meet the identified information needs of the healthcare providers, managers
and others.
Individuals in the organisation who generate, collect, analyse and use data and information are
educated and trained to effectively participate in managing information. Such education and training
enables these individuals to:
• understand the security and confidentiality of data and information;
• use measurement instruments, statistical tools, and data analysis methods;
• assist in interpreting data;
• use data and information to help in decision making;
• educate and support the participation of patients and families in care processes; and
• use indicators to assess and improve care and work processes.
Individuals are appropriately educated and trained in regard to their responsibilities, job descriptions,
and data and information needs.
Information management technology represents a major investment of resources for a healthcare
organisation. For this reason, technology is carefully matched to the current and future needs of the
organisation, and the organisation's resources. Available technology needs to be integrated with
existing information management processes, and serves to integrate the activities of all the
departments and services of the organisation. This level of co-ordination requires that key clinical and
managerial staff participate in the selection process. The management of the organization ensures
that the staff have the required supplies, registers, check lists, forms etc required for data
management.
6.1.3 Criteria
6.1.3.1. The organisation’s information management plan, once complete and approved as necessary, is
implemented.
6.1.3.2. Sufficient staff support the implementation.
6.1.3.3. Decision-makers and others are provided with appropriate training in the principles of information
management.
6.1.3.4. Required technology and other resources support the implementation.
6.1.4. The organisation has a process to aggregate data for user needs.
Intent of 6.1.4

The organisation collects and analyses aggregated data to support patient care and management of
the organisation. Aggregated data provide a profile of the organisation over time and allow for
comparison between the organisation's various performance improvement activities. In particular,
aggregated data from risk management, utility system management, infection control and utilisation
review can help the organisation to understand its current performance and identify opportunities for
improvement.
6.1.4 Criteria
6.1.4.1. The organisation has a process to aggregate data.
6.1.4.2. Clinical and managerial data and information are integrated as needed to support decision-making.
6.1.4.3. The data and information, to be regularly aggregated to meet the needs of agencies outside the
organisation are determined.
6.1.4.4. Aggregated data and information are used to support patient care.
6.1.4.5. Aggregated data and information are used to support management of the organisation.
6.1.4.6. Aggregated data and information are used to support the quality management programmes.
6.1.5. The organisation contributes to external databases when required by laws or

regulations.
Intent of 6.1.5
By participating in external performance databases, an organisation can compare its performance with
that of other similar organisations locally, nationally or internationally. Performance comparison is an
effective tool for identifying opportunities for improvement and documenting the organisation's
performance level. Healthcare networks and those purchasing or paying for health care often ask for
such information.
6.1.5 Criteria
6.1.5.1. The organisation has a process to participate in or use information from external databases.
6.1.5.2. Data or information are contributed to external databases as required by law or regulation.
6.1.5.3. The organisation compares its performance with that of other, similar organisations, using external
reference databases.
6.1.5.4. Security and confidentiality are maintained when contributing to or using external databases.
6.2. Provision of data

6.2.1. The data and information needs of those within and outside the organisation
are met on a timely basis, at the desired frequency and in a format that meets user
expectations.
Intent of 6.2.1
The format and methods of disseminating data and information to the intended user are tailored to
meet the user's expectations. Dissemination strategies include:
• providing only those data and information, which the user requests or needs;
• formatting the report to aid use in the decision process;
• providing reports at the frequency needed by the user;
• linking sources of data and information; and
• providing interpretation or clarification of data.
Clinical care providers, researchers, educators and managers often need information to assist with
their responsibilities. Such information may include scientific and managerial literature, clinical

practice guidelines, research findings and educational methodologies. The Internet, printed materials
in a library, on-line search sources, and personal materials are all valuable sources of information.
The information management process makes it possible to combine information from various sources
and generate reports to support decision-making. In particular, the combination of clinical and
managerial information supports the leaders of the organisation to plan collaboratively. The
information management process supports leaders with longitudinal and comparative data.
6.2.1 Criteria
6.2.1.1. Data and information dissemination meet user needs.
6.2.1.2. Information is provided according to a time frame that meets user expectations.
6.2.1.3. Users receive data and information in a format that aids their intended use.
6.2.1.4. Current scientific and other information support
patient care.
6.2.1.5. Current scientific and other information support clinical education.
6.2.1.6. Current scientific and other information support research.
6.2.1.7. Current scientific and other information support management.
6.3. Clinical information

6.3.1. There is a clinical record for each patient, which contains sufficient information
to identify the patient, support the diagnosis, justify the treatment, document the
course and results of treatment, and promote continuity of care among healthcare
providers.
Intent of 6.3.1
Each organisation has a process to assess the quality and completeness of patient records. That
process is a part of the organisation's performance improvement activities and is carried out regularly.
Clinical record review is based on a representative sample (a sample representing the practitioners
providing care and of the types of care provided). The medical staff, nursing staff, and other relevant
clinical professionals, who are authorised to make entries in the patient record conduct the review
process. The focus of the review is on the quality of the record and clinical information available
during the care process. Thus, the organisation's record review process includes the review of the
records of patients currently receiving care as well as the records of discharged patients.
6.3.1 Criteria
6.3.1.1. The specific content of clinical records has been determined by the organisation.
6.3.1.2. Standardised diagnosis and procedure codes are used.
6.3.1.3. Symbols and definitions are standardised.
6.3.1.4. Patient clinical records are reviewed regularly.
6.3.1.5. The review is conducted by medical, nursing and other staff, who are authorised to make entries in
patient records or to manage patient information.
6.3.1.6. The review uses a representative sample.
6.3.1.7. Records of active and discharged patients are included in the review process.
6.3.1.8. The review focuses on the timeliness, legibility and completeness of the clinical record.
6.3.1.9. Record contents required by laws or regulations are included in the review process.
6.3.2. There is a system for storage of health records, which meets the needs of
confidentiality and safety.

Intent of 6.3.2
Health record management must be implemented by a person with suitable training and experience.
The manager controls the safe storage and retrieval of files. Files must be readily available each time
the patient visits a healthcare professional, and therefore must be filed in such a way that they are
easily identified. Policies and procedures, as well as managerial supervision, ensure the safety and
confidentiality of files. Loss of information may be through electronic failure, fire, flood or theft. The
organisation develops and implements a policy that guides the retention of patient records and other
data and information. Patient records and other data and information are retained for sufficient periods
to comply with law and regulation and support patient care, the management of the organisation, legal
documentation, research and education. The retention policy is consistent with the confidentially and
security of such information. When the retention period is complete, patient records and other data
and information are destroyed appropriately.
6.3.2 Criteria
6.3.2.1. A designated individual is responsible for the storage, maintenance and retrieval of health records.
6.3.2.2. The health record manager is suitably trained and experienced in health record management.
6.3.2.3. The health record manager ensures that policies and procedures are available to guide the staff and
that they are implemented.
6.3.2.4. Policies and procedures relate to the safeguarding of information in the record against loss, damage,
breach of confidentiality or use by unauthorised persons.
6.3.2.5. Policies and procedures relate to records which are kept separately from the main record (e.g.
accident and emergency and psychiatric records).
6.3.2.6. Originals of all reports by medical, nursing and other health professionals are filed in the records.
6.3.2.7. There is a system that allows for the rapid retrieval and distribution of health records.
6.3.2.8. There is a communication system for the requesting of files.
6.3.2.9. There is an effective monitoring system (e.g.by using tracer cards) whereby records can be traced
within the facility at all times.
6.3.2.10. The filing system allows for incorrectly filed records to be easily identified (e.g. by using colour
coding).
6.3.2.11. There is provision for authorised access to patient records at all times.
6.3.2.12. The storage space for health records is secure against unauthorised entry.
6.3.3. The organisation has a policy on the retention of patient records and other
data and information.
6.3.3 Criteria
6.3.3.1. The retention process provides expected confidentiality and security.
6.3.3.2. Policies and procedures are developed for health record destruction, specifying the criteria for
selection and the method of destruction of records.
6.3.3.3. Records, data and information are destroyed appropriately.

7.Health and Safety
Overview of Health and Safety

Healthcare organisations work to provide a safe, functional and supportive facility for patients,
families, the staff and visitors. To reach this goal, the physical facility and medical and other hospital
equipment must be effectively managed.
In particular, the management of the organisation must strive to:
• identify, evaluate, reduce and control hazards and risks;
• prevent accidents and injuries; and
• maintain a safe environment.
Effective management includes the planning, education and monitoring of resources needed to safely
and effectively support the clinical services provided. All staff are educated about the facility, how to
reduce risks, and how to monitor and report situations that pose risks. Criteria are used to monitor
important systems and identify needed improvements.
Planning should consider the following areas, when appropriate to the facility and activities of the
organisation:
• Occupational health and safety programmes – the organisation complies with legislation relating to
health and safety and risk management.
• Fire safety – property and occupants are protected from fire and smoke.
• Emergencies – responses to epidemics, disasters and emergencies are planned and effective.
• Hazardous materials – handling, storage and use of radioactive, flammable and other materials are
controlled, and hazardous waste is safely disposed of.
• Security – property and occupants are protected from harm and loss.
The provision of health and safety services, emergency planning and other aspects of providing a safe
environment all require the staff to have the necessary knowledge and skills for their implementation.

Standards
7.1. Occupational health and safety programmes

7.1.1. Suitably trained or qualified individuals direct the planning and implementation
of the occupational health and safety management programme in terms of current
legislation.
Intent of 7.1.1
Legislation describes the health and safety measures to be implemented by organisations. ,
Proper management to ensure the safety of the staff, patients and visitors includes:
• planning of all aspects of the programme;
• implementation of the programme;
• education of the staff;
• testing and monitoring of the programme; and
• periodic review and revision of the programme.
Monitoring of all aspects of the programme provides valuable data to make improvements in the
programme and further reduce risks within the organisation.
7.1.1 Criteria
7.1.1.1. There is a documented health and safety programme.
7.1.1.2. There is an appointed health and safety committee.
7.1.1.3. The responsibilities and duties of these persons are written into job descriptions, with signed
acceptances.
7.1.1.4. There is evidence that written notice is given when these persons no longer function as members or
representatives.
7.1.1.5. Meetings are held with health and safety representatives, when requested by the staff or the
management of the organisation, and at least quarterly.
7.1.1.6. Agendas and minutes of health and safety meetings are made available to the staff.
7.1.1.7. Policies and procedures guide the activities of the health and safety committee and the staff of the
organisation.
7.1.1.8. The staff are consulted via health and safety representatives on matters relating to health and safety.
7.1.1.9. The health and safety committee evaluates all negative incidents, and makes recommendations for
the prevention of similar future incidents.
7.1.1.10. The heath and safety programme provides for consistent management and continuity over time.
7.1.2. Risks to the health and safety of staff, patients or visitors are assessed, and
control measures introduced in order to minimise or eliminate risk and promote
safety.
Intent of 7.1.2
To plan effectively, the organisation must be aware of all the risks present in the facility. The goal is
to prevent accidents and injuries, maintain safe and secure conditions for patients, families, the staff
and visitors, and reduce and control hazards and risks.
This can be done by comprehensively inspecting the facility, noting everything from sharp and broken
furniture that could injure people, to locations where there is no escape from fire. This periodic
inspection is documented and helps the organisation plan and carry out improvements and budget for
longer term facility upgrading or replacement. Analysis of staff absenteeism and sickness provides
data for planning for risk management, for example analysis of back injuries causing staff sickness and
absenteeism.

Then, with an understanding of the risks present in the organisation's physical facility, the organisation
can develop a proactive plan to reduce those risks for patients, families, the staff and visitors. This
plan includes safety, security and hazardous materials.
7.1.2 Criteria
7.1.2.1. A formal process is used for the identification of risks to the organisation, the staff, patients and
visitors.
7.1.2.2. There is a documented risk management plan to eliminate or reduce the identified risks.
7.1.2.3. Regular risk assessments are recorded, and the results made available to the staff.
7.1.2.4. There is a system for assessing risks to the health or safety of the staff attached to any work.
7.1.2.5. The staff do not undertake tasks or use equipment or machinery, until they have been trained in their
handling or have been assessed as capable of doing so.
7.1.2.6. There are monitoring mechanisms to ensure that staff members adhere to safe systems of work,
including the use of protective clothing.
7.1.2.7. Vulnerable groups of workers are identified.
7.1.2.8. Areas of the organisation are assessed to determine the extent of manual handling required.
7.1.2.9. Where there is risk of injury, it has been determined, whether it is possible to avoid manual handling,
or to provide mechanical aids in place of the latter.
7.1.2.10. There is a mechanism to ensure that the staff are aware of risks and their consequences.
7.1.2.11. Documented information, on the safe handling and storage of hazardous substances, is available and
provided to the management of the organisation.
7.1.2.12. First aid is available to the staff.
7.1.2.13. The risk management plan is effective in the reduction/elimination of risks and the maintenance of
safe conditions for patients, families, the staff and visitors.
7.1.3. Where the organization provides occupational health services, such services
are organized to ensure a safe and health workplace for employees, meet the needs
of the patients served, and are provided in accordance with ethical and professional
practices and legal requirements.
7.1.3 Criteria
7.1.3.1. Occupational health services are provided in accordance with relevant standards promulgated by
local, provincial and national guidelines, laws and regulations.
7.1.3.2. Occupational health service personnel are informed of the potential workplace hazards for each
employee.
7.1.3.3. Occupational health service personnel have the necessary and appropriate training, credentials and
skills to carry out their responsibilities.
7.1.3.4. Occupational health service personnel participate in continuing medical education in occupational
health.
7.1.3.5. Occupational health service personnel have appropriate access to a physician with expertise and
credentials in occupational health care.
7.1.3.6. Occupational health service personnel have access to and utilize, as appropriate, consultative
services associated with evaluating workplace hazards such as industrial hygiene, workplace
toxicology and epidemiology.
7.1.3.7. Occupational health service personnel
have ready access to appropriate reference materials regarding occupational health care.
7.1.3.8. Medical complaints by employees are managed with consideration given to the relationship to the
workplace environment and work practices.
7.1.3.9. Medical complaints by employees are managed with consideration given to the employee’s fitness to
continue present work practices.
7.1.3.10. Medical complaints by employees are managed with consideration given to any disability that may
have been sustained.
7.1.3.11. The management of an acute injury includes measures to minimize disability and to return the
employee, as soon as possible, to an optimal functional state.
7.1.3.12. Employees, absent from work, are evaluated to ensure that they have regained sufficient health to be
returned to their particular work place.
7.1.3.13. Such evaluation includes, but is not limited to, the extent and duration of the condition that caused the
absence from work.

7.1.3.14. Such evaluation includes, but is not limited to, the extent and duration of potential hazards that may
affect the employee’s health.
7.1.3.15. Data, relating to sickness and absenteeism, are analysed and monitored to reduce risks.
7.1.3.16. Pre-employment examinations are provided, that consider the health of the individual and the
requirements of the prospective workplace.
7.1.3.17. Medical surveillance evaluations of employees are conducted at appropriate intervals to identify, as
early as possible, adverse effects from exposure to workplace hazards.
7.1.3.18. Lifestyle habits (weight, diet, exercise, alcohol and/or tobacco use, etc.) are assessed, when potential
exposure to hazardous agents may be affected by those habits.
7.1.3.19. Personal information about an employee, that is unrelated to the ability to perform the specified job
safely, is handled in a confidential manner. Such information is only disclosed to an employer, if there
is a need for it and if the employee has given permission to do so.
7.2. Fire safety

7.2.1. The organisation inspects patient care buildings for fire safety and has a plan
to reduce evident fire risks for the protection of patients, the staff and visitors.
Intent of 7.2.1
Fire is an ever-present risk in a healthcare organisation. Thus, every organisation needs to plan how
it will keep its occupants safe in case of fire or smoke. The plan places particular emphasis on:
• the prevention of fires through the reduction of risks, such as the safe storage and handling of
potentially flammable materials;
• the preention of hazards, related to any construction in, or adjacent to, the buildings occupied by
patients;
• the provision of safe and unobstructed means of exit in the event of a fire;
• the display of clearly depicted fire escape routes;
• the availability of early warning, and early detection systems such as fire patrols, smoke detectors,
or fire alarms;
• the availability of current inspection reports from local fire departments, and
• the availability of suppression mechanisms such as water hoses, chemical suppressants or
sprinkler systems.
These actions, when combined, will give patients, families, the staff and visitors adequate time to
safely exit the facility, in the event of a fire or smoke. These actions are effective regardless of the
age, size or construction of the facility.
The organisation's fire safety plan details the:
• frequency of inspection, testing and maintenance of fire protection and safety systems, consistent
with requirements;
• process for testing, at least twice per year, the plan for the safe evacuation of the facility in the
event of a fire or smoke;
• education requirements for the staff, to effectively protect and evacuate patients when an
emergency occurs; and
• requirement that each staff member participate in at least one emergency preparedness test per
year.
All inspections, tests and maintenance procedures are documented.
The organisation develops and implements a policy and plan to eliminate smoking in the organisation's
facilities, or to limit smoking to designated non-patient care areas. This plan applies to all patients,
families, the staff and visitors. The organisation's smoking policy identifies any exceptions to the policy
related to patients, such as medical or psychiatric reasons why a patient may be permitted to smoke,

and those individuals permitted to grant such an exception. When an exception is made, the patients
smokes in a designated, non-treatment area, away from other patients.
7.2.1 Criteria
7.2.1.1. There is a programme in place to ensure that all occupants of the organisation’s facilities are safe
from fire and smoke emergencies or hazards.
7.2.1.2. The programme includes the assessment of fire risks when construction is present or adjacent to the
facility.
7.2.1.3. The programme includes the early detection of fire and smoke.
7.2.1.4. The programme includes the abatement of fire and containment of smoke.
7.2.1.5. The programme includes safe exit from the facility when fire and smoke emergencies occur.
7.2.1.6. The programme includes the location of fire-fighting equipment.
7.2.1.7. Notices indicating fire and emergency exits and escape routes are visible at appropriate locations.
7.2.1.8. Flammable materials are clearly identified and labelled, and stored separately in fireproof containers.
7.2.1.9. Fire detection and abatement systems are inspected, tested and maintained at a frequency
determined by the organisation.
7.2.1.10. Inspection, testing and maintenance of fire equipment and systems are documented.
7.2.1.11. The fire and smoke safety evacuation plan is tested at least twice a year.
7.2.1.12. The staff are trained to participate in the fire and smoke safety plan.
7.2.1.13. There is a documented inspection report/certification from the Local Fire Authority, that the facility
complies with relevant fire safety regulations.
7.2.1.14. The organisation has implemented a policy and plan, to eliminate or limit cigarette smoking, which
applies to patients, families, visitors and the staff.
7.2.1.15. There is a process to grant exceptions to the plan to certain patients.
7.3. Disaster preparedness

7.3.1. The organisation develops a plan to respond to likely community emergencies,
epidemics, and natural or other disasters.
Intent of 7.3.1
Community emergencies, epidemics and disasters may directly involve the organisation, such as
damage to patient care areas as a result of an earthquake, or flu that affects the staff. To respond
effectively, the organisation develops a plan, and tests it. The plan provides processes for alternate
care sites, if needed, and alternate sources of medical supplies, communications equipment, and other
materials.
The organisation participates in community-wide emergency preparedness efforts. The organisation
tests its response at least once a year, it is has been designated as a receiving site in the community.
7.3.1 Criteria
7.3.1.1. The organisation plans its response to likely community emergencies, epidemics, and natural or other
disasters.
7.3.1.2. The organisation participates in community-wide disaster planning.
7.3.1.3. The plan is tested at least once a year.
7.3.1.4. There is a plan to obtain medical supplies in an emergency.
7.3.1.5. Communication equipment is available in emergencies.
7.3.2. The organisation plans for any internal incident that might occur, and
rehearses and evaluates the plan.
Intent of 7.3.2

Organisations should be prepared for bomb threats, hostage taking, explosions and the consequent
loss of vital services.
There may be a time when it is necessary to evacuate patients. This can only be done quickly and
effectively if the staff have been trained in evacuation procedures. There is therefore a written and
updated plan, which is regularly rehearsed and evaluated.
7.3.2 Criteria
7.3.2.1. An internal incident and emergency plan (ie dealing with armed robberies, bomb threats, explosions
and loss of vital services) has been developed with the assistance of experts.
7.3.2.2. The staff are issued with written details of their role in the event of an incident.
7.3.2.3. Each department in the facility is made aware of its function and prepares an action plan.
7.3.2.4. There is a rehearsal of the plan at least once a year.
7.3.2.5. There is a written report and evaluation of each rehearsal.
7.3.2.6. The plan deals with the assignment of staff members to specific tasks and responsibilities.
7.3.2.7. The plan deals with the use of alarm systems and signals.
7.3.2.8. The plan deals with the communication channels with relevant persons.
7.3.2.9. The plan deals with the evacuation routes and procedures.
7.4. Clinical/healthcare and other waste

7.4.1. The organisation has a plan for the handling, storage and disposal of
clinical/healthcare and other wastes.
Intent of 7.4.1
Hazardous wastes are identified by the organisation and are safely controlled according to a plan.
Such materials and wastes include chemicals, chemotherapeutic agents, radioactive materials,
household wastes, hazardous gases and vapours, and other regulated medical and infectious wastes.
All clinical waste is regarded as hazardous or potentially hazardous.
The plan is included in the organisation's risk management plan.
7.4.1 Criteria
7.4.1.1. There is a plan for the handling of all waste in the organisation.
7.4.1.2. The plan identifies documentation requirements including any permits, licences, or other regulatory
requirements.
7.4.1.3. The plan includes segregation, storage control (inventory), transportation and disposal of wastes.
7.4.1.4. The plan includes the identification and management of clinical/healthcare wastes. The plan includes
the identification and management of recyclable materials.
7.4.1.5. The plan includes labelling of hazardous materials and wastes.
7.4.1.6. The plan includes the procedures to be adopted when a spill of a hazardous chemical or infectious
material occurs.
7.4.1.7. The plan includes reporting and investigation of spills, exposures and other incidents.
7.4.1.8. The plan includes the use of proper protective equipment and procedures during the use, or spill of,
or exposure to hazardous materials.
7.5. Security
7.5.1. The organisation provides a security service that ensures the safeguarding
and protection of buildings, patients, the staff and visitors.
Intent of 7.5.1
The organisation has a responsibility to ensure that its staff, patients and visitors are safe from attacks
or theft by intruders. The health and safety committee identifies areas and groups that are vulnerable

and require added security. Plans are developed and implemented through the health and safety
committee to provide protection. The loss of organisation property must be prevented as far as
possible through the implementation of security systems.
Security officers need to be aware of their powers and duties, relating to the restriction of access to the
premises and the apprehension of intruders.
7.5.1 Criteria
7.5.1.1. A 24-hour security system is maintained for the routine monitoring and safeguarding of the building,
patients, the staff and visitors.
7.5.1.2. The person in charge of security is a member of the health and safety committee.
7.5.1.3. The powers and duties of security officers are clearly defined.
7.5.1.4. The security system includes external and internal security of the hospital.
7.5.1.5. Safety and security systems are developed with the staff.
7.5.1.6. Security systems include alarms at strategic areas.
7.5.1.7. Security staff are easily recognisable.
7.5.1.8. The building is evaluated to identify areas requiring security doors and locks.
7.6. Training in health and safety

7.6.1. The organisation educates and trains all staff about their roles in providing a
safe and effective patient care facility.
Intent of 7.6.1
The organisation's staff provide the main source of contact with patients, families and visitors. Thus,
they need to be educated and trained to carry out their roles in identifying and reducing risks,
protecting others and themselves, and creating a safe and secure facility.
Each organisation must determine the type and level of training for its staff, and then carry out and
document a programme for such training and education. The programme can include group
instruction, or printed educational materials, form a component of new staff orientation, or involve
some other mechanism that meets the needs of the organisation. The programme includes instruction
of the processes for reporting potential risks, reporting incidents and injuries, and handling hazardous
and other materials that pose risks to themselves and others.
The organisation plans a programme designed to periodically test staff knowledge related to
emergency procedures, including fire safety procedures, the response to hazards such as the spill of a
hazardous material, and the use of medical equipment that poses a risk to patients and the staff.
Knowledge can be tested through a variety of means such as individual or group demonstrations, the
staging of mock events such as an epidemic in the community, the use of written or computer tests, or
other means suitable to the knowledge being tested. The organisation documents who was tested
and the results of the testing.
The organisation provides training to the staff to prepare them for their roles in external or internal
emergencies.
7.6.1 Criteria
7.6.1.1. For each component of the organisation’s health and safety programme, there is planned education
to ensure that the staff can effectively carry out their responsibilities.
7.6.1.2. The staff are trained and knowledgeable about their role in the organisation’s plan for safety, security,
hazardous materials and emergencies.
7.6.1.3. The staff can describe and/or demonstrate their role in response to a fire.
7.6.1.4. The staff can describe and/or demonstrate actions to eliminate, minimise, or report health, safety,
security and other risks.

7.6.1.5. The staff can describe and/or demonstrate precautions, procedures, and participation in the storage,
handling, and disposal of hazardous wastes and materials, and in related emergencies.
7.6.1.6. The staff can describe and/or demonstrate procedures and their role in internal and community
emergencies and disasters.
7.6.1.7. Staff knowledge is tested regarding their role in maintaining a safe and effective facility.
7.6.1.8. Staff training and testing are documented as to who was trained and tested, and the results.

7.7.1. The health and safety committee implements a formalised proactive quality
improvement programme.
Intent of 7.7.1
throughout the organisation. Within each department or service, it is the responsibility of managers
and leaders to ensure that standards are set for the particular department, as part of the organisation's
quality improvement plan. This requires co-ordination with the organisation's steering committee.
Departmental managers use available data and information to identify priority areas for quality
monitoring and improvement. Indicators focus on high-risk areas. Results of quality improvement
monitoring are used to reduce identified risks to staff and patients.
7.7.1 Criteria
7.7.1.1. A monitoring programme provides data on incidents, injuries, and other events that support planning
and further risk reduction.
7.7.1.2. Monitoring data are used to improve the risk management programme.

8.Quality Management and Improvement
Overview of Quality Management and Improvement

This chapter describes a comprehensive approach to quality management and improvement. The
approach includes the following processes:
• planning for improvement in quality;
• monitoring how well processes work through indicator data collection;
• analysing the data, and
• implementing and sustaining changes that result in improvement.
These processes, when performed well, provide the framework for the organisation and its leaders to
achieve a commitment to provide quality patient care in a safe, well-managed environment.
This approach is rooted in the daily work of individual healthcare professionals and other staff
members. As physicians and nurses assess patient needs and provide care, this chapter can help
them understand how to make real improvements to help their patients. Similarly, managers, support
staff and others can apply these standards to their daily work to understand how processes can be
made more efficient and resources used more wisely.
The continuous monitoring, analysing and improving of clinical and managerial processes must be well
organised and have clear leadership to achieve maximum benefit. This organised approach takes
into account that most clinical care processes involve more than one profession. Thus, efforts to
improve those processes must be guided by an overall framework for quality management and
improvement activities in the organisation. These international accreditation standards address the full
spectrum of clinical and managerial activities of a healthcare organisation, and include the framework
for improving those activities.
Standards in other quality-evaluation programmes, outside of accreditation, address certain aspects of

this quality management and improvement framework. Such programmes include:
• the ISO 9000 standards, which offer a common, international basis, for qualifying suppliers, for
quality management capabilities;
• the European Foundation for Quality Management (EFQM), which provides a step-by-step
approach to quality assessment and improvement, and
• the Malcolm Baldridge National Quality Award (United States) which provides
quality improvement and quality control criteria.
Although the above programmes address some parts of a healthcare organisation's operations and
may be useful in developing and carrying out a quality management programme, they do not
comprehensively address all aspects of such an organisation, especially clinical assessment and
patient care. Thus, the framework presented in the standards is suitable for a wide variety of
structured programmes, and less formal approaches to quality management and improvement.
This framework can also incorporate traditional monitoring programmes such as those related to
unexpected events (risk management) and resource use (utilisation management).

Over time, organisations that follow this framework will:

• develop greater leadership support for an organisation-wide programme;
• train and involve more staff in monitoring and improvement activities;
• set clearer priorities for what to monitor and what to improve;
• base decisions on indicator data, and
• make improvements based on comparison with other organisations, nationally and internationally.

Standards
8.1. Quality leadership and design

8.1.1. There is a written organisation-wide quality management and improvement
programme.
Intent of 8.1.1
If an organisation is to initiate and maintain improvement, leadership and planning are essential.
The governance of the organisation is as important as the managers and clinical care providers in the
organisation. Each leader participates in establishing the organisation's commitment, approach to
improvement, and programme management and supervision. The leaders, through their vision and
support, shape the quality culture of the organisation.
Improvement programmes are most effective when they are planned and organisation-wide. The
framework for these is provided in a written plan for the programme, which is inclusive of all services
in the organisation, and of all related quality activities such as infection control and risk management
activities.
Well-designed processes or services draw on a variety of information sources. Good process design:
• is consistent with the organisation's mission and plans;

• meets the needs of patients, families, the staff and others;
• uses current practice guidelines, clinical standards, scientific literature, and other relevant
evidence-based information on clinical practice design;
• is consistent with sound business practices;
• considers relevant risk management information;
• uses information from related improvement activities; and
• integrates and connects processes and systems.
A primary responsibility of leaders is to set priorities. Organisations typically find more opportunities
for quality monitoring and improvement than they have human and other other resources to
accomplish. Therefore, the leaders provide focus for the organisastion's quality monitoring and
improvement activities. The leaders prioritise those critical, high-risk or problem-prone processes that
most directly relate to the quality of care and the safety of the environment. The leaders use available
data and information to identify areas that must be prioritised.
8.1.1 Criteria
8.1.1.1. There is a relevant and appropriate system/mechanism for the execution/implementation of a quality
management and improvement programme.
8.1.1.2. Managerial and clinical leaders and other relevant stakeholders participate in the design,
execution/implementation, evaluation and modification or redesign of the quality management and
8.1.1.3. The quality management and improvement programme reflects the scope of service delivery in
relation to managerial, clinical and support services (including formal educational services where
applicable).
8.1.1.4. The quality management and improvement programme reflects all components and quality activities
in relation to standard/indicator development, monitoring/evaluation and remedial action.
8.1.1.5. There is an appropriate system/mechanism for the evaluation and redesign/modification of the quality
management and improvement programme.
8.1.1.6. There is a relevant/appropriate quality management and improvement reporting and communication
system to all stakeholders concerned.
8.1.1.7. The leaders set priorities for monitoring activities.

8.1.1.8. The leaders set priorities for improvement activities.
8.1.2. The leaders co-ordinate the quality management and improvement

programme, and provide technological and other support.
Intent of 8.1.2
Available resources are used well, when the quality management and improvement activities are
centrally co-ordinated. This co-ordination is achieved through a quality steering group, or a committee,
that provides for effective supervision of quality management and improvement activities throughout
the organisation. One of the responsibilities of such a group is to communicate information about the
quality management and improvement programme to the staff on a regular basis.
The monitoring of clinical and managerial functions in a healthcare organisation results in the
accumulation of data and information. An understanding of how well the organisation is doing rests on
the analysis of the data and information over time and comparison with other organisations. For large
or complex organisations this tracking and comparison may require technology and/or staff members
with data management experience. The leaders of an organisation understand the monitoring and
improvement priorities in terms of this necessary support. They provide the support consistent with
the resources and quality management priorities of the organisation.
8.1.2 Criteria
8.1.2.1. There is co-ordination of the organisation’s quality management and improvement programme with all
services.
8.1.2.2. Both managerial and clinical the staff closest to the activities being monitored studied or improved,
participate in quality management and improvement activities.
8.1.2.3. Information on the programme is communicated to staff on a regular basis.
8.1.2.4. The leaders understand the technology and other support requirements for tracking and comparing
monitoring results.
8.1.2.5. The leaders provide the required technology and support.
8.1.3. Medical, nursing and other leaders are familiar with the concepts and methods
of quality management and improvement.
Intent of 8.1.3
The primary purpose of a healthcare organisation is to provide patient care and to work to improve
patient care outcomes over time, through the application of quality management and improvement
principles. Thus, the medical, nursing and other clinical leaders of an organisation need to:
§ be familiar with the concepts and methods of quality management and improvement;
§ personally participate in quality management and improvement processes;
§ ensure that clinical monitoring includes opportunities for the monitoring of professional
performance; and
§ use available and relevant clinical practice guidelines to provide the scientific basis for such
monitoring, as part of a structured clinical audit.
8.1.3 Criteria
8.1.3.1. Medical, nursing and other clinical leaders are familiar with the concepts and methods of quality
management and improvement.
8.1.3.2. Medical, nursing and other clinical leaders participate in relevant quality management and
improvement processes.

8.1.3.3. Professional performance is monitored as part of clinical monitoring.

8.1.3.4. Medical, nursing and other clinical leaders use available and relevant clinical practice guidelines in
clinical monitoring as part of a structured clinical audit.
8.1.4. The staff are provided with the required knowledge and skills to enable them to
participate in quality improvement programmes.
Intent of 8.1.4
Participation in data collection and analysis, and the planning and implementation of quality
improvements requires knowledge and skills that most staff members do not have or do not use
regularly. Thus, when asked to participate in the programme, the staff receive training consistent with
their role in the planned activity. The organisation identifies or provides a knowledgeable trainer for
this education. Staff are permitted to attend training as part of their assigned responsibilities.
The staff selected to participate in management and improvement programmes are those closest to
the activities or processes being monitored, studied or improved. Both managerial and clinical staff
participate. Over time, a larger and larger number of staff have the opportunity to be trained and
participate.
8.1.4 Criteria
8.1.4.1. There is a relevant educational/training programme to equip the staff with the necessary
competencies (knowledge, skills and attitudes) for the design, execution/implementation and
evaluation of a quality management and improvement programme.
8.1.4.2. The training programme for the staff is consistent with their role in the quality management and
8.1.4.3. A knowledgeable individual provides the training.
8.1.4.4. Staff members are permitted to participate in the training as part of their work assignment.
8.2. Quality monitoring

8.2.1. There is a relevant clinical quality monitoring system.
Intent of 8.2.1
A primary purpose of monitoring is to prevent medical errors, eg medication errors or surgery to the
wrong limb. Also, monitoring helps reduce risks, such as falls and exposure to radioactive materials.
Monitoring data are critical to designing, creating and maintaining a safe environment for patients, the
staff and visitors.
Quality management and improvement are data driven. Because most organisations have limited
resources, they cannot collect data to monitor everything they want. Thus, each organisation must
choose which clinical and managerial processes and outcomes are most important to monitor based
on its mission, patient needs and services provided. Monitoring often focuses on those processes that
are high-risk to patients, provided in high volume, or are problem prone.
The leaders of an organisation have the responsibility to make the final selection of the key measures
to be included in the organisation's monitoring activities. The measures selected relate to those
important clinical and managerial areas identified.
For each of these areas leaders decide:
• the process, procedure or outcome to be measured;
• how measurement will be accomplished; and
• the frequency of measurement.
Identification of the process, procedure or outcome to be measured is clearly the most important step.

The measure needs to focus on, for example:

• risk points in processes;
• procedures that frequently present problems or are performed in high volume; and
• outcomes that can be clearly defined and are under the control of the organisation.
For example, an organisation may choose to measure a particular surgical procedure, or a class of
surgical procedures. The organisation may wish to measure the process used to select a surgical
procedure, or the process of aspects of the procedure. Medical staff may wish to measure the
outcomes of treatment methods.
Frequency of data collection is associated with how frequently the particular process is used or
procedure performed. Sufficient data from all cases or a sample of cases are needed to support
conclusions and recommendations. New measures are selected when a current measure no longer
provides data useful for the analysis of the process, procedure or outcome.
When errors or adverse events occur, the organisation and its leaders evaluate the processes that led
to the error or adverse event. This evaluation is based on the collection of data on the targeted area.
Faulty processes are redesigned, tested and monitored to ensure that the same or similar errors or
events do not occur again.
To monitor processes, the organisation needs to determine how to organise the monitoring activities,
how often to collect data, and how to incorporate data collection into daily work processes.
8.2.1 Criteria
8.2.1.1. Clinical staff identify key measures to monitor clinical areas.
8.2.1.2. Clinical monitoring includes patient assessment.
8.2.1.3. Clinical monitoring includes surgical procedures carried out.
8.2.1.4. Clinical monitoring includes the use of antibiotics and other medications and medication errors.
8.2.1.5. Clinical monitoring includes the use of anaesthesia.
8.2.1.6. Clinical monitoring includes the use of blood and blood products.
8.2.1.7. Clinical monitoring includes the availability, contents and use of patient records.
8.2.1.8. Clinical monitoring includes infection control, surveillance and reporting.
8.2.1.9. Clinical monitoring includes measures related to structures, processes and outcomes.
8.2.1.10. Clinical monitoring includes laboratory and radiology safety and quality control programmes.
8.2.1.11. The scope, method and frequency are identified for each clinical measure.
8.2.1.12. Data collection is used to study clinical areas targeted for improvement.
8.2.1.13. Data collection is used to monitor and evaluate the effectiveness of clinical improvements.
8.2.2. There is a relevant managerial quality monitoring system.

Intent of 8.2.2
A primary purpose of monitoring is to prevent medical errors, eg medication errors or surgery to the
wrong limb. Also, monitoring helps reduce risks, such as falls and exposure to radioactive materials.
Monitoring data are critical to designing, creating and maintaining a safe environment for patients, the
staff and visitors.
Quality management and improvement are data driven. Because most organisations have limited
resources, they cannot collect data to monitor everything they want. Thus, each organisation must
choose which clinical and managerial processes and outcomes are most important to monitor based
on its mission, patient needs and services provided. Monitoring often focuses on those processes that
are high-risk to patients, provided in high volume, or are problem prone.
The leaders of an organisation have the responsibility to make the final selection of the key measures
to be included in the organisation's monitoring activities. The measures selected relate to those

important clinical and managerial areas identified.

For each of these areas leaders decide:
• the process, procedure or outcome to be measured;
• how measurement will be accomplished; and
• the frequency of measurement.
Identification of the process, procedure or outcome to be measured is clearly the most important step.
The measure needs to focus on, for example:
• risk points in processes;
• procedures that frequently present problems or are performed in high volume; and
• outcomes that can be clearly defined and are under the control of the organisation.
For example, an organisation may choose to measure a particular surgical procedure, or a class of
surgical procedures. The organisation may wish to measure the process used to select a surgical
procedure, or the process of aspects of the procedure. Medical staff may wish to measure the
outcomes of treatment methods.
Frequency of data collection is associated with how frequently the particular process is used or
procedure performed. Sufficient data from all cases or a sample of cases are needed to support
conclusions and recommendations. New measures are selected when a current measure no longer
provides data useful for the analysis of the process, procedure or outcome.
When errors or adverse events occur, the organisation and its leaders evaluate the processes that led
to the error or adverse event. This evaluation is based on the collection of data on the targeted area.
Faulty processes are redesigned, tested and monitored to ensure that the same or similar errors or
events do not occur again.
To monitor processes, the organisation needs to determine how to organise the monitoring activities,
how often to collect data, and how to incorporate data collection into daily work processes.
8.2.2 Criteria
8.2.2.1. The leaders identify key measures to monitor managerial areas.
8.2.2.2. Managerial monitoring includes the procurement of routinely required supplies and medications
essential to meet patient needs.
8.2.2.3. Managerial monitoring includes reporting of activities as required by laws and regulations.
8.2.2.4. Managerial monitoring includes risk management.
8.2.2.5. Managerial monitoring includes utilisation management.
8.2.2.6. Managerial monitoring includes patient and family expectations and satisfaction.
8.2.2.7. Managerial monitoring includes staff expectations and satisfaction.
8.2.2.8. Managerial monitoring includes demographics and diagnoses.
8.2.2.9. Managerial monitoring includes financial management.
8.2.2.10. Managerial monitoring includes the surveillance, control and prevention of events that jeopardise the
safety of patients, families and the staff.
8.2.2.11. Managerial monitoring includes measures related to structures, processes and outcomes.
8.2.2.12. The scope, method and frequency are identified for each managerial measure.
8.2.2.13. Data collection is used to study managerial areas targeted for improvement.
8.2.2.14. Data collection is used to monitor and evaluate the effectiveness of managerial improvements.
8.3. Analysis of data

8.3.1. There is a relevant system for the analysis of data.
Intent of 8.3.1

To reach conclusions and make decisions, data must be aggregated, analysed and transformed into
useful information. Data analysis involves individuals with an understanding of information
management and skills in data aggregation methods, and in the use of various statistical tools. Data
analysis involves the individuals responsible for the process or outcome being measured. These
individuals may be clinical, managerial or a combination. Thus, data analysis provides continuous
feedback of quality management information to help those individuals make decisions and
continuously improve clinical and managerial processes.
The organisation determines how often data are aggregated and analysed. The frequency depends
on the activity or area being measured, the frequency of measurement, and the organisation's
priorities. For example, clinical data may be analysed weekly to meet local regulations, and patient fall
data may be analysed monthly if falls are infrequent. Thus aggregation of data at points in time
enables the organisation to judge a particular process's stability or a particular outcome's predictability
in relation to expectations.
When an organisation detects or suspects undesirable change from what is expected, it initiates
intense analysis to determine where best to focus improvement. In particular, intense analysis is
initiated when levels, patterns or trends vary significantly or undesirably from:
• what is expected;
• that of other organisations; or
• recognised standards.
Certain events related to specific processes always result in intense analysis to understand the cause
and prevent recurrence. When appropriate to the organisation's services, these events include:
• confirmed transfusion reactions;
• significant adverse drug reactions;
• significant medication errors;
• significant discrepancy between preoperative and postoperative diagnoses; and
• significant adverse anaesthetic events.
Each organisation establishes which events are significant and the process for their intense analysis.
When undesirable events can be prevented, the organisation works to carry out preventive changes.
The goal of data analysis is to be able to compare an organisation in four ways:
• with itself over time, such as month to month, or one year to the next;
• with other similar organisations, such as through reference databases;
• with standards, such as those set by accrediting and professional bodies, or those set by laws or
regulations; and
• with desirable practices identified in the literature, such as practice guidelines.
These comparisons help the organisation to understand the source and nature of undesirable change
and help to focus improvement efforts.
Understanding statistical techniques is helpful in data analysis, especially in interpreting variation and
in deciding where improvement needs to occur. Run charts, control charts, histograms and Pareto
charts are examples of statistical tools useful in understanding trends and variations in health care.
8.3.1 Criteria
8.3.1.1. Data are aggregated, analysed and transformed into useful information.

8.3.1.2. Individuals with appropriate clinical or managerial experience, knowledge and skills participate in the
process.
8.3.1.3. The frequency of data analysis is appropriate to the process under study.
8.3.1.4. The frequency of data analysis meets the requirements of the organisation.
8.3.1.5. Intense analysis of data takes place when significant adverse levels, patterns or trends occur.
8.3.1.6. The organisation has established which events are significant.
8.3.1.7. The organisation has established the process for intense analysis of these events.
8.3.1.8. Significant events are analysed when they occur.
8.3.1.9. Comparisons are made over time within the organisation.
8.3.1.10. Comparisons are made with similar organisations, when possible.
8.3.1.11. Comparisons are made with standards, when appropriate.
8.3.1.12. Comparisons are made with known desirable practices.
8.3.1.13. Statistical tools and techniques are used in the analysis process when suitable.
8.4. Achieving and sustaining quality

8.4.1. Improvement in quality is achieved and sustained.
Intent of 8.4.1
The organisation uses the information from data analysis to identify potential improvements or reduce
(or prevent) adverse events. Routine monitoring data, as well as data from intensive assessments,
contribute to an understanding of where improvement should be planned, and what priority should be
given to the improvement. In particular, clinical and managerial leaders plan improvements to those
data collection areas requiring priority.
The organisation uses appropriate resources and involves those individuals, disciplines, and
departments closest to the processes or activities to be improved. Responsibility for planning and
carrying out improvement is assigned to individuals or to a team. Any needed training is provided and
information management or other resources are made available.
Once planned, data are collected during a test period to demonstrate that the planned change was
actually an improvement. To ensure that the improvement is sustained, monitoring data are then
collected for, ongoing analysis. Effective changes are incorporated into standard operating
procedures and any necessary staff education is carried out. The organisation documents those
improvements achieved and sustained, as part of its quality management and improvement
programme.
8.4.1 Criteria
8.4.1.1. Improvement activities are undertaken in those priority areas, which have been identified by the
organisation’s leaders as requiring priority.
8.4.1.2. Assignments are made and support provided.
8.4.1.3. Staff are trained and the necessary resources are allocated.
8.4.1.4. The organisation uses a consistent process to plan and implement improvements.
8.4.1.6. Those responsible for improvement are assigned.
8.4.1.7. Policy changes, necessary to plan and carry out the improvements, are made.
8.4.1.8. The organisation documents the improvements achieved and sustained.
8.4.1.8. Changes are planned.
8.4.1.9. Changes are tested.
8.4.1.10. Changes that resulted in improvements are implemented.
8.4.1.12. There is documentation of successful improvements.
8.4.1.13. The documentation contributes to the development of strategic improvement plans.


9.Prevention and Control of Infections
Overview of Prevention and Control of Infections

Standards
9.1. Infection control management

9.1.1. The organisation designs and implements a co-ordinated programme to
reduce the risks of nosocomial infections in patients and healthcare workers.
Intent of 9.1.1
For an infection prevention and control programme to be effective, it must be comprehensive,
encompassing both patient care and employee health. The programme is appropriate to the size and
geographic location of the organisation, the services offered by the organisation, and the patients seen
by the organisation.
Infections can enter the organisation via patients, their families, staff members, volunteers, vectors,
visitors, and other individuals such as trade representatives. Thus, all areas of the organisation, where
these individuals are found, must be included in the programme of infection surveillance, prevention
and control.
One or more individuals, acting on a full-time or part-time basis, direct the programme. Their
qualifications depend on the activities they will carry out and may be met through education, training
and experience. Their responsibilities include, for example, the setting of criteria for defining
nosocomial infections and establishing data collection methods and reporting processes. Co-ordination
involves communication with all parts of the organisation, to ensure that the programme is continuous
and proactive.
Whatever the mechanism chosen by the organisation to co-ordinate the infection control programme,
medical and nursing staff are represented and engaged in the activities. Others may be included as
determined by the size of the organisation and the services offered (for example, epidemiologist, data
collection expert, central sterilisation manager, operating theatre supervisor).
The individual, committee, or other mechanism must also monitor those housekeeping and other
support service practices, which may lead to the spread of infection, eg cleaning, linen supply, laundry
services and waste disposal.
Information is essential to an infection control programme. Current scientific information is required to
understand and implement effective surveillance and control activities; practice guidelines provide
information on preventive practices and infections associated with clinical services; and applicable
laws and regulations define elements of the basic programme and reporting requirements. Information
supports the tracking of risks, rates and trends in nosocomial infections, data analysis, interpretation
and presentation of findings. In addition, infection control programme data and information are
managed with those of the organisation's quality management and improvement programme.
9.1.1 Criteria
9.1.1.1. There is a programme to reduce the risk of nosocomial infections to patients and healthcare workers.
9.1.1.2. The programme is appropriate to the size and geographic location of the organisation, the services
offered, and the patients served.
9.1.1.3. Co-ordination of infection control activities involves medical, nursing and other staff as appropriate to
the organisation.
9.1.1.4. All patient, staff and visitor areas of the organisation are included in the infection control programme.
9.1.1.5. Responsibility for co-ordinating the overall programme is assigned to one individual or a committee.
9.1.1.6. The individuals are competent to manage the scope and complexity of the programme.
9.1.1.7. The infection control programme is based on current scientific knowledge, accepted practice
guidelines, and applicable laws and regulations.

9.1.1.8. Information management systems support the infection control programme.
9.1.2. The organisation establishes those epidemiologically important infections,

infection sites, and associated devices that will provide the focus of efforts to prevent
and reduce the incidence of nosocomial infections.
Intent of 9.1.2
The programme addresses the infection issues that are epidemiologically important to the
organisation. Each organisation must establish those epidemiologically important infections, infection
sites, and associated devices that will provide the focus of efforts to prevent and reduce the incidence
of nosocomial infections. They consider, as appropriate, infections that involve:
• the respiratory tract – such as the procedures and equipment associated with intubation,
mechanical ventilatory support and tracheostomy;
• the urinary tract – such as the invasive procedures and equipment associated with indwelling
urinary catheters, urinary drainage systems, and their care, and so on;
• intravascular invasive devices – such as the insertion and care of central venous catheters,
peripheral venous lines;
• surgical wounds – such as their care and type of dressing and associated aseptic procedures.
9.1.2 Criteria
9.1.2.1. The infection control programme includes prevention of the spread of respiratory tract infections, and
focuses on processes that may lead to infection.
9.1.2.2. The infection control programme includes prevention of the spread of urinary tract infections, and
focuses on processes that may lead to infection.
9.1.2.3. The infection control programme includes prevention of the spread of infection through intravascular
invasive devices.
9.1.2.4. The infection control programme includes prevention of the spread of infection through surgical
wounds.
9.2. Infection control processes

9.2.1. The organisation identifies the procedures and processes associated with the
risk of infection, and implements strategies to reduce infection risk.
Intent of 9.2.1
Healthcare organisations assess and care for patients using many simple and complex processes,
each associated with a level of infection risk to patients and the staff. It is thus important for an
organisation to review those processes and, as appropriate, implement needed policies, procedures,
educational and other activities to reduce the risk of infection.
9.2.1 Criteria
9.2.1.1. The organisation has identified those processes associated with infection risk and implemented
strategies to reduce such risk.
9.2.1.2. Identified processes include, as appropriate to the services provided by the organisation equipment
cleaning, disinfection and sterilisation;
9.2.1.3. Identified processes include, as appropriate to the services provided by the organisation laundry and
linen management;
9.2.1.4. Identified processes include, as appropriate to the services provided by the organisation disposal of
infectious waste;
9.2.1.5. Identified processes include, as appropriate to the services provided by the organisation disposal of
clinical/healthcare waste;

9.2.1.6. Identified processes include, as appropriate to the services provided by the organisation ensuring that
food preparation, handling, storage and distribution are safe and comply with laws, regulations and
current acceptable practices;
9.2.1.7. Identified processes include, as appropriate to the services provided by the organisation
housekeeping services;
9.2.1.8. Identified processes include, as appropriate to the services provided by the organisation operation of
the mortuary area/holding room for the deceased;
9.2.1.9. Identified processes include, as appropriate to the services provided by the organisation separating
patients with communicable diseases from those patients and staff members, who are susceptible to
infection due to immuno-suppression or other reasons;
9.2.1.10. Identified processes include, as appropriate to the services provided by the organisation the
management of viral haemorrhagic fevers;
9.2.1.11. Identified processes include, as appropriate to the services provided by the organisation the handling
and disposal of blood and blood components.
9.2.1.12. Processes associated with risk are described in written documents.
9.2.2. Protective clothing, disinfectants and barrier techniques are available and are
used correctly when required.
Intent of 9.2.2
Hand washing, barrier techniques and disinfecting agents are fundamental to infection prevention and
control. The organisation identifies those situations in which the use of masks and gloves is required
and provides training in their correct use. Soap and disinfectants are located in those areas where
hand washing and disinfecting procedures are required. Staff are educated in proper hand washing
and disinfecting procedures.
9.2.2 Criteria
9.2.2.1. The organisation identifies those situations for which protective clothing is required.
9.2.2.2. Protective clothing is correctly used in those situations.
9.2.2.3. The organisation identifies those areas where hand washing and disinfecting procedures are
required.
9.2.2.4. Policy defines the hand-washing facilities required e.g. hand-wash basins, elbow taps, paper towels,
covered pedal-operated waste bins, alcohol hand rubs.
9.2.2.5. Hand washing and disinfecting procedures are used correctly in those areas.
9.2.2.6. Gloves, masks, soap and disinfectants are available and are used correctly when required.
9.3. Obtaining of laboratory cultures

9.3.1. Laboratory cultures are obtained from designated sites in the organisation
associated with significant infection risk.
Intent of 9.3.1
Infection surveillance procedures rely on specimen collection from those persons and areas of the
organisation thought to be associated with a high incidence or risk of infection, such as operating
theatres. The infection control programme includes identifying those persons and sites and collecting
specimens from those persons and sites. The sites associated with the activities described in 9.2.1 are
frequently included in such surveillance activities. Those individuals who collect specimens are trained
in the proper collection and handling of microbiological specimens.
9.3.1 Criteria
9.3.1.1. The organisation identifies those sites from which specimens are to be collected.
9.3.1.2. The organisation defines the conditions under which specimens, for example nasal swabs, will be
collected from identified persons.

9.3.1.3. The organisation identifies the frequency with which specimens are collected.
9.3.1.4. Policies and procedures describe how specimens are taken and sent to the laboratory and action is
taken when laboratory reports identify pathogenic organisms.
9.3.1.5. Specimens are collected and handled according to guidelines.
9.4. Infection control quality management

9.4.1. The infection control programme has a quality management and improvement
programme which is integrated with the organisation’s overall programme for quality
management and improvement.
Intent of 9.4.1
The infection control process is designed to lower the risk of infection for patients, the staff and others.
To reach this goal, the organisation must proactively monitor and track risks, rates and trends in
nosocomial infections. The organisation uses monitoring information to improve infection prevention
and control activities and to reduce nosocomial infection rates to the lowest possible levels. An
organisation can best use monitoring data and information by understanding similar rates and trends in
other similar organisations and contributing data to infection-related databases.
9.4.1 Criteria
9.4.1.1. The organisation tracks infection risks, infection rates, and trends in nosocomial infections.
9.4.1.2. Monitoring includes using indicators related to infection issues that are epidemiologically important to
the organisation.
9.4.1.3. The organisation uses risk, rate and trend information to design or modify processes to reduce
nosocomial infections to the lowest possible levels.
9.4.1.4. The organisation compares its infection control rates with other organisations through comparative
databases.
9.4.1.5. The results of infection monitoring in the organisation are regularly communicated to management
medical,and nursing staff as well as to all other relevant departments in the organisation.
9.4.1.6. The organisation reports information on infections to appropriate external public health agencies.
9.5. Infection control education for the staff

9.5.1. The organisation provides education on infection control practices to the staff,
patients, and, as appropriate, family and other caregivers.
Intent of 9.5.1
For an organisation to have an effective infection control programme, it must educate staff members
about the programme when they begin work in the organisation and regularly thereafter. The education
programme includes professional staff, clinical and non-clinical support staff, and even patients and
families, if appropriate. The education focuses on the policies, procedures and practices that guide the
organisation's infection control programme. The education also includes the findings and trends from
the monitoring activities.
9.5.1 Criteria
9.5.1.1. All staff are orientated to the policies, procedures and practices of the infection control programme.
9.5.1.2. The organisation provides ongoing in-service training about infection control.
9.5.1.3. All staff are educated in infection control when new policies are implemented and when significant
trends are noted in surveillance data.
9.5.1.4. Medical, nursing and other professional staff are included in the programme.
9.5.1.5. Patients and families are included when appropriate to the patient’s needs and condition.


CARE OF PATIENTS
Inpatient units
10.Medical/Surgical/Paediatric & Obstetrics
Overview of Medical/Surgical/Paediatric & Obstetrics

A healthcare organisation's main purpose is patient care. Providing the most appropriate care in a
setting that supports and responds to each patient's unique needs requires a high level of planning and
co-ordination.
Certain activities are basic to patient care, including planning and delivering care to each patient,
monitoring the patient to understand the results of the care, modifying care when necessary and
completing the follow-up.
Many medical, nursing, pharmaceutical, rehabilitation and other types of healthcare providers may
carry out these activities. Each provider has a clear role in patient care. Credentialing, registration,
law and regulation, an individual's particular skills, knowledge and experience, and organisational
policies or job descriptions determine that role. The patient, the family or trained caregivers may carry
out some of this care.
A plan for each patient is based on an assessment of needs. That care may be preventive, palliative,
curative or rehabilitative and may include the use of anaesthesia, surgery, medication, supportive
therapies, or a combination of these. A plan of care is not sufficient to achieve optimal outcomes
unless the delivery of the services is co-ordinated, integrated and monitored.
Continuity of care
From entry to discharge or transfer, several departments, services and different health care providers
may be involved in providing care. Throughout all phases of care, patient needs are matched with
appropriate resources within and, when necessary, outside the organisation. This is accomplished by
using established criteria or policies that determine the appropriateness of transfers within the
organisation.
Processes for continuity and co-ordination of care among physicians, nurses and other healthcare
providers must be implemented in and between all services.
Leaders of various settings and services work together to design and implement the required
processes to ensure co-ordination of care.

Standards
10.1. Co-ordination of patient care

10.1.1. During all phases of care, there are qualified individuals responsible for the
patient's care.
Intent of 10.1.1
The individuals who bear overall responsibility for the patient's care or for a particular phase of care
are identified in the patient's record or in a manner that is made known to the staff.
10.1.1 Criteria
10.1.1.1. The individuals responsible for the patient's care are designated.
10.1.1.2. The individuals responsible for the patient's care are qualified.
10.1.1.3. The individuals responsible for the patient's care are identified and made known to the patient and
other staff.
10.1.2. The delivery of services is integrated and co-ordinated amongst care

providers.
Intent of 10.1.2
The co-ordination of patient care depends on the exchange of information between the
multidisciplinary team. This can be through verbal, written or electronic means according to
appropriate policies determined by the organisation. Clinical leaders should use techniques to better
integrate and co-ordinate care for their patients (for example, team-delivered care, multi-departmental
patient care rounds, combined care planning forums, integrated patient records, case managers).
The process for working together will be simple and informal when the patient's needs are not
complex.
The patient, family and others are included in the decision process when appropriate.
The patient's record contains a history of all care provided by the multidisciplinary team, and is made
available to all relevant caregivers who are authorised to have access to its content.
10.1.2 Criteria
10.1.2.1. Care planning is integrated and co-ordinated among all care providers.
10.1.2.2. The patient's record is available to the care providers to facilitate the exchange of information.
10.1.2.3. The records are up to date to ensure the transfer of the latest information.
10.1.2.4. Information exchanged includes the patient's health status.
10.1.2.5. Information exchanged includes a summary of the care provided.
10.1.2.6. Information exchanged includes the patient's progress.
10.1.2.7. The author can be identified for each patient record entry.
10.1.2.8. The date of each patient record entry can be identified.
10.2. Assessment of patients

10.2.1. All patients cared for by the organisation have their health care needs
identified through an established assessment process.
Intent of 10.2.1
When a patient enters a ward or department, the specific information required and the procedures for
obtaining and documenting it depend on the patient's needs and on the setting in which care is being

provided.
The organisation defines, in writing, the scope and content of assessments to be performed by each
clinical discipline within its scope of practice and applicable laws and regulations.
These findings are used throughout the care process to evaluate patient progress and understand the
need for reassessment. It is essential that assessments are documented well and can be easily
retrieved from the patient's record.
10.2.1 Criteria
10.2.1.1. The organisation provides policies and procedures for assessing patients on admission and during
ongoing care.
10.2.1.2. Only those individuals permitted by applicable laws and regulations or by registration perform the
assessments.
10.2.1.3. The scope and content of assessment by each discipline is defined.
10.2.2. Clinical practice guidelines are used to guide patient assessment and reduce
unwanted variation.
Intent of 10.2.2
Practice guidelines provide a means to improve quality and assist practitioners and patients in making
clinical decisions. Guidelines are found in the literature under many names, including practice
parameters, practice guidelines, patient care protocols, standards of practice and clinical pathways.
Regardless of the source, the scientific basis of guidelines should be reviewed and approved by
organisation leaders and clinical practitioners before implementation. This ensures that they meet
the criteria established by the leaders and are adapted to the community, patient needs and
organisation resources. Once implemented, guidelines are reviewed on a regular basis to ensure their
continued relevance.
10.2.2 Criteria
10.2.2.1. Organisational and clinical leaders set criteria to select clinical practice guidelines.
10.2.2.2. Guidelines for the assessment of patients are implemented.
10.2.2.3. The maternal and fetal conditions and the progress of labour are recorded on a partogram in every
labour.
10.2.2.4. Criteria are available for referral of complicated labour.
10.2.2.5. Guidelines are used in clinical monitoring as part of a structured clinical audit.
10.2.2.6. Guidelines are reviewed and adapted on a regular basis after implementation.
10.2.3. Assessments are performed within appropriate time frames.

Intent of 10.2.3
The healthcare organisation determines the time frame for completing assessments. This may vary in
the different settings within the organisation. When an assessment is partially or entirely completed
outside the organisation, the findings are verified on admission to the organisation.
10.2.3 Criteria
10.2.3.1. Written procedures ensure that assessments are performed within appropriate time frames and that
they are adequately documented in the patients' records.
10.2.3.2. Assessments are completed within the time frames established by the organisation.
10.2.3.3. When required by the organisation, the time of entry can be identified.
10.2.3.4. The findings of assessments performed outside the organisation are verified on admission.

10.2.3.5. Any significant changes in the patient's condition since the report are noted in the patient's record.
10.2.4. Each patient has an initial assessment that complies with current policies,
procedures and guidelines.
Intent of 10.2.4
The initial assessment of a patient is critical for the identification of the needs of the patient and
initiation of the care process. Planning for discharge is initiated during the initial assessment process.
Patients' social, cultural and family status are important factors that can influence their response to
illness and care. Families can be of considerable help in these areas of assessment and in
understanding the patient's wishes and preferences. Economic factors are assessed as part of the
social assessment, particularly when the patient and his/her family will be responsible for the cost of all
or a portion of the care.
A functional and nutritional assessment allows for the patient to be referred for specialist care if
necessary.
Certain patients may require a modified assessment, eg very young patients, the frail or elderly, those
terminally ill or in pain, patients suspected of drug and/or alcohol dependency, and victims of abuse
and neglect. The assessment process is modified in accordance with local laws and regulations, the
culture of the patient population, and involves the family when appropriate.
The outcome from the patient's initial assessment is an understanding of the patient's medical and
nursing needs so that care and treatment can begin.
When the medical assessment was conducted outside the organisation, a legible copy is placed in the
patient's record. Any significant changes in the patient's condition since the assessment are recorded.
10.2.4 Criteria
10.2.4.1. Each patient admitted has an initial assessment that meets organisation policy.
10.2.4.2. The initial assessment includes health history.
10.2.4.3. The initial assessment includes physical examination.
10.2.4.4. The initial assessment includes functional and nutritional assessment where the need is identified.
10.2.4.5. The initial assessment includes psychological assessment.
10.2.4.6. The initial assessment includes social, cultural and economic assessment.
10.2.4.7. The initial assessment results in an understanding of the care the patient is seeking.
10.2.4.8. The initial assessment results in an understanding of any previous care.
10.2.4.9. The initial assessment results in an initial diagnosis.
10.2.4.10. The initial assessment results in the identification of the patient's medical and nursing needs.
10.2.4.11. The organisation identifies those patient populations and special situations for which the initial
assessment process is modified.
10.2.4.12. The organisation identifies patients in pain during the assessment process.
10.2.4.13. Special patient populations receive individualised assessments.
10.2.4.14. A process is in place to identify needs for discharge planning at the initial assessment.
10.2.5. Preoperative anaesthetic assessments are documented.

Intent of 10.2.5
The preoperative anaesthesia assessment determines if the patient is a good candidate for the
planned surgery and may significantly influence the pre- and intra-operative management. The clinical
assessment and results of investigations must be available to the doctor performing the assessment.
In an emergency, the initial medical assessment may be limited to the patient's apparent needs and

condition.
Appropriate reassessments are essential to modify and guide effective treatment.
10.2.5 Criteria
10.2.5.1. Patients have a medical assessment performed before surgery or any procedure e.g. bone marrow
aspiration, lumbar puncture etc. under anaesthetic.
10.2.5.2. The initial medical assessment of patients is documented before anaesthesia.
10.2.5.3. Patients have the results of diagnostic tests recorded before anaesthesia.
10.2.5.4. Patients have a preoperative diagnosis recorded before anaesthesia.
10.2.5.5. For emergency patients, the medical assessment is appropriate to their needs and condition.
10.2.5.6. If surgery is to be performed, a note must be made in the patient's record in accordance with a written
policy.
10.2.5.7. All patients are reassessed at appropriate intervals, to determine their response to care and
treatment, and to plan for continued treatment or discharge.
10.2.6. Healthcare professionals responsible for patient care collaborate to analyse

and integrate assessment information.
Intent of 10.2.6
A patient benefits most when the staff responsible for the patient work together to analyse the
assessment findings and to combine this information into a comprehensive picture of his or her
condition. From this collaboration, the patient's needs are identified, the order of their importance is
established, and care decisions are made.
10.2.6 Criteria
10.2.6.1. Assessment findings are documented in the patient's record and are readily available to those
responsible for the patient's care.
10.2.6.2. Patient assessment data and information are analysed and integrated by those responsible for the
patient's care.
10.2.6.3. Patient needs are prioritised on the basis of assessment results.
10.2.6.4. The patient and/or his or her family participate in the decisions regarding the priority needs to be met.
10.3. Patient care

10.3.1. Adequate resources are available for the provision of safe care to patients in
the ward.
Intent of 10.3.1
In order to provide safe patient care, each unit requires adequate resources. The physical facilities
required include adequate office accommodation for staff, sluice rooms which are hygienically clean at
all times, treatment and dressing rooms, and adequate storage space for clean linen. Cleaning
equipment is safely stored in a room or cupboard expressly for this purpose. There are adequate toilet
and bathing facilities for the number of patients in the ward (at least one toilet for every 8 patients, and
one bath or shower for every 12 patients).
Each delivery room has:
• at least one cardio-tocograph machine;
• an infant warming and resuscitation cart;
• an incubator with adjustable temperature and separate oxygen supply;
• a fetal monitor;
• equipment for inhalation analgesia.
There is a nursery which is temperature controlled and has:

• suitable bassinettes;
• photo-therapy lights;
• a panel for the viewing of babies.
There is milk kitchen dedicated to infant feeding which has:
• a fridge dedicated for milk feeds;
• washing-up facilities dedicated to the preparation of infant feeds.
There is adequate lighting and ventilation. Emergency call systems are available at bedsides and in
bathrooms and toilets. The emergency call system is connected to the emergency power system.
There is at least one oxygen point and one vacuum point for every 2 beds. Where there is no piped
oxygen and vacuum supply, there are mobile oxygen cylinders and vacuum pumps. All necessary
fittings for oxygen and suction are in place and working satisfactorily. Each bed is serviced by at least
one electrical socket outlet. Each ward is provided with a socket outlet that is connected to the
emergency power supply.
Resuscitation equipment is immediately available from each section of the ward. Resuscitation
equipment includes at least:
• Defibrillator with adult and infant paddles
• ECG monitor
• CPR board
• Suction
• Ambu bag or equivalent
• Endotracheal tubes and laryngoscopes
• Oral airways
• Tracheotomy sets where there is no theatre.
The resuscitation equipment is available in adult and paediatric sizes.
Each resuscitation trolley includes:
• appropriate facilities for intravenous therapy and drug administration (including paediatric
sizes);
• drugs for cardiac and respiratory arrest, coma, fits and states of shock (including paediatric
doses);
• plasma expanders.
10.3.1 Criteria
10.3.1.1. Patient and staff accommodation in the service is adequate to meet patient care needs.
10.3.1.2. Oxygen and vacuum supplies meet the needs of patients for care.
10.3.1.3. There is evidence that equipment is maintained in accordance with the policies of the organisation.
10.3.1.4. Resuscitation equipment is available in accordance with the policies of the organisation.
10.3.1.5. Where there are no piped oxygen installations, there is a documented procedure for ensuring that
cylinder pressures (i.e. contents) are constantly monitored while patients are receiving oxygen.
10.3.1.6. Each patient has access to a nurse call system at all times.
10.3.1.7. Electricity and water is available in accordance with the policies of the organisation.
10.3.1.8. There is a dedicated area for the preparation of infant feeds.
10.3.2. The care provided to each patient is planned and written in the patient's
record.

Intent of 10.3.2
A single, integrated plan is preferable to the entry of a separate care plan by each provider.
Collaborative care and treatment team meetings or similar patient discussions are recorded.
Individuals qualified to do so order diagnostic and other procedures. These orders must be easily
accessible if they are to be acted on in a timely manner. Locating orders on a common sheet or in a
uniform location in patient records facilitates the correct understanding and carrying out of orders.
An organisation decides:
• which orders must be written rather than verbal;
• who is permitted to write orders; and
• where orders are to be located in the patient record.
The method used must respect the confidentiality of patient care information.
When guidelines and other related tools are available and relevant to the patient population and
mission of the organisation, there is a process to evaluate and adapt them to the needs and resources
of the organisation, and to train staff to use them.
10.3.2 Criteria
10.3.2.1. The care for each patient is planned and noted in the patient's record.
10.3.2.2. The planned care is provided and noted in the patient's record.
10.3.2.3. Any patient care meetings or other discussions are noted in the patient's record.
10.3.2.4. All procedures and diagnostic tests ordered and performed are written into the patient's record.
10.3.2.5. Orders are found in a uniform location in patient records.
10.3.2.6. Only those permitted to write orders do so.
10.3.2.7. The results of procedures and diagnostic tests performed are available in the patient's record.
10.3.2.8. Patients are re-assessed at intervals appropriate to their condition, plan of care and individual needs.
10.3.2.9. Re-assessments are documented in the patient's record.
10.3.2.10. The patient's plan of care is modified when the patient's needs change.
10.3.3. Compassionate care is provided to the dying and to those in pain.

Intent of 10.3.3
While pain may be a part of the patient experience, unrelieved pain has adverse physical and
psychological effects. The patient's right to appropriate assessment and management of pain is
respected and supported. The organisation has processes to:
• identify patients with pain during initial assessment and reassessment;
• communicate with, and provide education for, patients and families about pain management in the
context of their personal, cultural and religious beliefs and
• educate healthcare providers in pain assessment and management.
Dying patients have unique needs for respectful, compassionate care. Concern for the patient's
comfort and dignity guides all aspects of care during the final stages of life. To accomplish this, all
staff is made aware of the unique needs of patients at the end of life. These needs include treatment
of primary and secondary symptoms, pain management, response to the psychological, social,
emotional, religious and cultural concerns of the patient and family and their involvement in care
decisions.
10.3.3 Criteria
10.3.3.1. The organisation respects and supports the patient's right to appropriate assessment and
management of pain.

10.3.3.2. The organisation communicates with and provides education for patients and families about pain and
pain management.
10.3.3.3. The organisation educates health professionals in assessing and managing pain.
10.3.3.4. The unique needs of dying patients are recognised and respected within the organisation.
10.3.3.5. Staff provide respectful and compassionate care to dying patients.
10.3.4. Policies and procedures guide the care of high-risk patients and the provision
of high-risk services.
Intent of 10.3.4
Some patients are considered "high-risk" because of their age, condition or the critical nature of their
needs. Children and the elderly are commonly in this group as they may not speak for themselves,
understand the care process or participate in decisions regarding their care. Similarly, the frightened,
confused or comatose patient is unable to understand the care process when care needs to be
provided efficiently and rapidly.
A variety of services are considered "high-risk" because of the complex equipment needed to treat a
life-threatening condition (dialysis patients), the nature of the treatment (use of blood and blood
products) or the potential for harm to the patient (restraint).
Policies and procedures are important for staff to understand these patients and services, and to
respond in a thorough, competent and uniform manner. The clinical and managerial leaders take
responsibility for identifying the patients and services considered high-risk, using a collaborative
process to develop policies and procedures and training staff in their implementation.
Special facilities and safety measures required by children need to be specified.
Of particular concern is that the policies or procedures identify:
• how planning will occur;
• the documentation required for the care team to work effectively;
• special consent considerations;
• monitoring requirements;
• special qualifications or skills of staff involved in the care process; and
• availability and use of resuscitation equipment, including that for children.
Clinical guidelines and pathways are frequently helpful and may be incorporated in the process.
Monitoring provides the information needed to ensure that the policies and procedures are adequately
implemented and followed for all relevant patients and services.
10.3.4 Criteria
10.3.4.1. The organisation's clinical and managerial leaders identify high-risk patients and services.
10.3.4.2. Policies and procedures guide the care of emergency patients, including antenatal, intra-partum and
neonatal complications in obstetric patients.
10.3.4.3. Policies and procedures guide the handling, use and administration of blood and blood products.
10.3.4.4. Policies and procedures guide the management of contaminated blood supplies (expired, opened or
damaged container).
10.3.4.5. Policies and procedures guide the care of patients on life support or who are comatose.
10.3.4.6. Policies and procedures guide the care of patients with communicable diseases.
10.3.4.7. Policies and procedures guide the care of immuno-suppressed patients.
10.3.4.8. Policies and procedures guide the care of patients on dialysis.
10.3.4.9. Policies and procedures guide the use of restraint and the care of patients in restraint.
10.3.4.10. Policies and procedures guide the care of frail, dependent elderly patients.
10.3.4.11. Policies and procedures guide the care of young, dependent children.

10.3.4.12. Policies and procedures guide security of newborn babies.

10.3.4.13. Policies and procedures guide management of meconium-stained liquor.
10.3.4.14. Policies and procedures guide performing of episiotomies.
10.3.4.15. Policies and procedures guide Apgar scoring and evaluation.
10.3.4.16. Staff is trained and use the policies and procedures to guide care.
10.3.4.17. Patients receive care consistent with the policies and procedures.
10.3.5. Risks, benefits, potential complications, and care options are discussed with
the patient and his or her family or with those who make decisions for the patient.
Intent of 10.3.5
Patients and their families or decision-makers receive adequate information to participate in care
decisions. Patients and families are informed as to what tests, procedures and treatments require
consent and how they can give consent, for example verbally, by signing a consent form, or through
some other mechanism. Patients and families understand who may, in addition to the patient, give
consent. Designated staff is trained to inform patients and to obtain and document patient consent.
These staff members clearly explain any proposed treatments or procedures to the patient and, when
appropriate, the family. Informed consent includes:
• an explanation of the risks and benefits of the planned procedure;
• identification of potential complications; and
• consideration of the surgical and non-surgical options available to treat the patient.
In addition, when blood or blood products may be needed, information on the risks and alternatives is
discussed.
The organisation lists all those procedures that require written informed consent. Leaders document
the processes for the obtaining of informed consent.
The consent process always concludes with the patient signing the consent form, or the
documentation of the patient's verbal consent in the patient's record by the individual who provided the
information for consent. Documentation includes the statement that the patient acknowledged full
understanding of the information. The patient's surgeon or other qualified individual provides the
necessary information and the name of this person appears on the consent form.
10.3.5 Criteria
10.3.5.1. Patients and their families or decision-makers receive adequate information to enable them to
participate in care decisions.
10.3.5.2. There is a documented process for the obtaining of informed consent.
10.3.5.3. Patients are informed about their condition, and the proposed treatment.
10.3.5.4. Patients are informed about methods of delivery.
10.3.5.5. Patients are informed about potential benefits and drawbacks to the proposed treatment.
10.3.5.6. Patients are informed about the possible alternatives to the proposed treatment.
10.3.5.7. Patients are informed about the likelihood of successful treatment.
10.3.5.8. Patients are informed about possible problems related to recovery.
10.3.5.9. Patients are informed about possible results of non-treatment.
10.3.5.10. Patients know the identity of the physician or other practitioner responsible for their care.
10.3.5.11. When treatments or procedures are planned, patients know who is authorised to perform the
procedure or treatment.
10.3.5.12. The information is provided to patients in a clear and understandable way.
10.3.5.13. Patients and families participate in care decisions to the extent they choose.
10.3.5.14. The education includes the need for, risk of, and alternatives to blood and blood product use.
10.3.5.15. The information provided is recorded, with the record of the patient having provided written or verbal
consent.

10.3.6. Surgery performed is written in the patient's record to enable post-operative

care.
Intent of 10.3.6
A patient's post-surgical care is related to the findings and the surgical procedure.
10.3.6 Criteria
10.3.6.1. A post-operative diagnosis is documented.
10.3.6.2. A description of the surgical procedure, findings and any surgical specimens is documented.
10.3.6.3. The names of the surgeon, and other staff as required by law, are documented.
10.3.6.4. The surgical report is available within a time frame needed to provide post-surgical care to the patient.
10.3.7. Each patient's physiological status is continuously monitored immediately

after surgery and written in the patient's record.
Intent of 10.3.7
The monitoring is appropriate to the patient's condition and the procedure performed.
Results of monitoring influence intra- and post-operative decisions such as return to surgery, transfer
to another level of care and the need for further investigations or discharge.
10.3.7 Criteria
10.3.7.1. The patient's physiological status is monitored during the immediate post-surgery period.
10.3.7.2. Findings are entered into the patient's record.
10.3.7.3. Each patient's medical, nursing and other post-surgical care is planned.
10.3.7.4. The plan(s) is documented in the patient's record.
10.4. Medication
10.4.1. Medication use in the organisation complies with applicable laws and
regulations.
Intent of 10.4.1
Medication management is not only the responsibility of the pharmaceutical service but also of
managers and clinical care providers. Medical, nursing, pharmacy and administrative staff participate
in a collaborative process to develop and monitor policies and procedures.
Each organisation has a responsibility to identify those individuals with the requisite knowledge and
experience, and who are permitted by law, registration or regulations to prescribe or order
medications. In emergency situations, the organisation identifies any additional individuals permitted
to prescribe or order medications. Requirements for documentation of medications ordered or
prescribed and for using verbal medication orders are defined in policy.
Medications brought into the organisation by the patient or his or her family are known to the patient's
physician and are noted in the patient's record.
10.4.1 Criteria
10.4.1.1. Policies and procedures guide the safe prescribing, ordering and administration of medications in the
patient care unit.
10.4.1.2. Documentation requirements are stated.

10.4.1.3. The use of verbal medication orders is documented.

10.4.1.4. Relevant staff are trained in correct prescribing, ordering and administration practices.
10.4.1.5. Only those permitted by the organisation and by relevant law and regulation prescribe medication.
10.4.1.6. There is a process to place limits, when appropriate, on the prescribing or ordering practices of
individuals.
10.4.1.7. Medications brought into the organisation by the patient or his or her family are known to the patient's
10.4.2. Medications are safely administered

Intent of 10.4.2
Only staff who are suitably trained and experienced may administer medication to patients. The
responsibility of these persons for medication administration is documented. The safe administration of
medications requires a strict and comprehensive protocol.
The patient, physician, nurse, and other care providers work together to monitor patients on
medications. The purpose of monitoring is to evaluate the response to medication, adjust the dosage
or type of medication when needed, and to evaluate the patient for adverse effects.
The organisation identifies adverse effects that are to be recorded and those that must be reported
and establishes the mechanism for reporting adverse events. The reporting process is part of the
organisation's performance improvement programme. The programme is focused on the prevention of
medication errors through understanding the types of errors that occur. Improvements in medication
processes and staff training are used to prevent errors in the future. The pharmacy participates in such
staff training.
10.4.2 Criteria
10.4.2.1. Only those permitted by the organisation and by relevant laws and regulations administer
medications.
10.4.2.2. There is evidence that patients are identified before medications are administered.
10.4.2.3. Medications are checked against the original prescriptions and administered as prescribed.
10.4.2.4. Medications expiry dates are checked before administration.
10.4.2.5. Healthcare professionals monitor medication effects on patients collaboratively.
10.4.2.6. The organisation has identified those adverse effects that are to be recorded in the patient's record,
and those that must be reported to the organisation.
10.4.2.7. Adverse medication effects are observed and recorded.
10.4.2.8. Adverse effects are reported when required.
10.4.2.9. Medication errors are reported through a process and within a time frame defined by the organisation.
10.4.2.10. The medications prescribed for and administered to each patient are recorded.
10.4.3. Medications are stored in a safe and clean environment.

Intent of 10.4.3
Patient care units store medications in a clean and safe environment that complies with law, regulation
and professional practice standards.
10.4.3 Criteria
10.4.3.1. Medication is stored in a locked storage device or cabinet that is accessible only to authorised staff.
10.4.3.2. Scheduled drugs controlled by law are stored in a cabinet of substantial construction, for which only
authorised staff have the keys.
10.4.3.3. Medications are legibly marked and securely labelled.
10.4.3.4. Medications are stored in a clean environment.
10.4.3.5. Medication is stored in accordance with manufacturer's instructions relating to temperature, light and
humidity.

10.4.3.6. A refrigerator is available for those medications requiring storage at low temperatures.
10.4.3.7. The temperature of the refrigerator is monitored and recorded.
10.4.3.8. Controlled substances are accurately accounted for.
10.4.3.9. Expiry dates are checked (including those of emergency drugs), and drugs are replaced before expiry
date.
10.5. Food and nutrition therapy

10.5.1. Food and nutrition therapy appropriate for the patient and consistent with his
or her clinical care is regularly available.
Intent of 10.5.1
A qualified caregiver orders appropriate food or other nutrients. The patient participates in planning
and selecting foods, and the patient's family may, when appropriate, participate in providing food. They
are educated as to which foods are contraindicated, including information about any medications
associated with food interactions. When possible, patients are offered a variety of food choices
consistent with their nutritional status.
The nutritional status of the patients is monitored.
10.5.1 Criteria
10.5.1.1. Food, appropriate to the patient, is regularly available.
10.5.1.2. An order for food, based on the patients' nutritional status and needs, is recorded in the patient's file.
10.5.1.3. Patients have a variety of food choices consistent with their condition and care.
10.5.1.4. When families provide food, they are educated about the patient's diet limitations.
10.5.1.5. Patients assessed as being at nutrition risk receive nutrition therapy.
10.5.1.6. A collaborative process is used to plan, deliver and monitor nutrition therapy.
10.5.1.7. Nutrition therapy provided, either oral or intravenous, is written in the patient's record.
10.5.1.8. Response to nutrition therapy is monitored and recorded.
10.5.1.9. The hospital implements the principles of 'baby friendly hospital' with regard to breast feeding.
10.6. Patient and family education

10.6.1. Each patient's educational needs are assessed and written in his or her
record.
Intent of 10.6.1
Education is focused on the specific knowledge and skills that the patient and his or her family will
need to make care decisions, participate in care, and continue care at home.
Variables like educational literacy, beliefs and limitations are taken into account.
Each organisation decides the placement and format for educational assessment, planning and
delivery of information in the patient's record.
Education is provided to support care decisions of patients and families. In addition, when a patient or
family directly participates in providing care, for example changing dressings, feeding and
administration, they need to be educated.
On occasion, it is important that they be aware of any financial implications associated with care
choices, such as choosing to remain an inpatient rather than an outpatient.
Education in areas that carry high risk to patients is routinely provided by the organisation, for instance
safe and effective use of medications and medical equipment.
Community organisations that support health promotion and disease prevention education are

identified and, when possible, ongoing relationships are established.

10.6.1 Criteria
10.6.1.1. The patient's and family's education needs are assessed and recorded.
10.6.1.2. There is a uniform process for the recording of patient education information.
10.6.1.3. Patients and families learn about participation in the care process.
10.6.1.4. Patients and families learn about any financial implications of care decisions.
10.6.1.5. Patients are educated about relevant high health risks, e.g. safe use of medication and medical
equipment, or medicine and food interactions.
10.6.1.6. The organisation identifies and establishes relationships with community resources that support
continuing health promotion and disease prevention education.
10.6.1.7. Patients are referred to these organisations as appropriate.
10.6.2. Education methods consider the patient's and family's values and
preferences.
Intent of 10.6.2
Learning occurs when attention is paid to the methods used to educate patients and families. The
organisation selects appropriate educational methods and people to provide the education.
Staff collaboration helps to ensure that the information patients and families receive is comprehensive,
consistent, and as effective as possible.
10.6.2 Criteria
10.6.2.1. The patient and family are taught in a language and format that they can understand.
10.6.2.2. Those who provide education have the knowledge and communication skills for effective education.
10.6.2.3. Health professionals caring for the patient work collaboratively when appropriate.
10.6.2.4. Interaction between staff, the patient and family is noted in the patient's record.
10.7. Continuity of care

10.7.1. The organisation designs and carries out processes to provide continuity of
patient care services within the organisation.
Intent of 10.7.1
Patients frequently move between various care settings within the organisation. Without co-ordination
and effective transfer of information and responsibilities, errors of omission and commission may
occur, exposing the patient to avoidable risks.
10.7.1 Criteria
10.7.1.1. Established criteria or policies determine the appropriateness of transfers within the organisation.
10.7.1.2. Individuals responsible for the patient's care and its co-ordination are identified for all phases.
10.7.1.3. Continuity and co-ordination are evident throughout all phases of patient care.
10.7.1.4. The record of the patient accompanies the patient when transferred within the organisation.
10.7.2. There is a process to appropriately transfer patients to another organisation

to meet their continuing needs.
Intent of 10.7.2
Transfer may be for specialised consultation and treatment, urgent services, or for less intensive
services such as sub-acute care or long-term rehabilitation.

To ensure continuity of care, adequate information must accompany the patient.

Transfer may be a brief process with the patient alert and talking, or may involve continuous nursing or
medical supervision. The process for transferring the patient must consider transportation needs. The
qualifications of the individual accompanying the patient must be appropriate.
10.7.2 Criteria
10.7.2.1. There is a process for transferring patients to other organisations.
10.7.2.2. The transfer process addresses who is responsible during transfer.
10.7.2.3. The transfer process addresses the transfer of responsibility to another provider or setting.
10.7.2.4. The transfer process addresses the patient's continuing care needs.
10.7.2.5. The referring organisation determines that the receiving organisation can meet the patient's
continuing care needs, and establishes arrangements to ensure continuity.
10.7.2.6. Arrangements are in place with the receiving organisations to which patients are frequently
transferred.
10.7.2.7. The process for transferring the patient considers transportation needs.
10.7.2.8. Patients are accompanied and monitored by an appropriately qualified person during transfer.
10.7.2.9. When a patient is transferred to another organisation, the receiving organisation is given a written
summary of the patient's clinical condition and the interventions provided by the referring
organisation.
10.7.2.10. The transferring organisation documents the transfer in the organisation's patient record.
10.7.2.11. The reason(s) for the transfer is noted in the patient's record.
10.7.2.12. Any special conditions related to transfer are noted in the patient's record.
10.7.2.13. The condition of the patient before transfer is noted in the patient's record.
10.7.2.14. The healthcare organisation or other internal unit agreeing to receive the patient is noted in the
patient's record.
10.7.3. There is an organised process to appropriately discharge patients.

Intent of 10.7.3
The organisation begins to plan for the patients' continuing needs as early in the care process as
possible. Instructions for discharge and follow-up visits must be clear and provided in writing.
10.7.3 Criteria
10.7.3.1. There is a process, known to staff, to appropriately discharge patients.
10.7.3.2. The discharge is based on the patient's needs for continuity of care.
10.7.3.3. Planning for discharge, when appropriate, includes the family.
10.7.3.4. The organisation works with healthcare practitioners and agencies outside the organisation to ensure
timely and appropriate discharge.
10.7.3.5. The process considers the need for support services and continuity of care.
10.7.3.6. Patients and, as appropriate, their families are given understandable follow-up instructions by the
medical practitioner in the discharge note at referral or discharge.
10.7.3.7. Follow-up instructions include any return for follow-up care, and when and where to obtain urgent
care.
10.7.4. A discharge summary is written for each patient, and made available in the
patient's record.
Intent of 10.7.4
The discharge summary is one of the most important documents to ensure continuity of care and
facilitate correct management at subsequent visits. Information provided by the organisation may
include when to resume daily activities, preventive practices relevant to the patient's condition and,
when appropriate, information on coping with disease or disability.

10.7.4 Criteria
10.7.4.1. A discharge summary is written by the medical practitioner, at discharge of each patient.
10.7.4.2. Each record contains a copy of the discharge summary.
10.7.4.3. The summary contains the reason for admission.
10.7.4.4. The summary contains the significant findings.
10.7.4.5. The summary contains the diagnosis of main and significant illnesses.
10.7.4.6. The summary contains the results of investigations that will influence further management.
10.7.4.7. The summary contains all procedures performed.
10.7.4.8. The summary contains medications and treatments administered.
10.7.4.9. The summary contains the patient's condition at discharge.
10.7.4.10. The summary contains discharge medications and follow-up instructions.
10.7.4.11. The discharge summary is available for follow-up visits.
10.7.4.12. When appropriate the patient is given a copy of the discharge summary.

service.
Intent of 10.8.1
It is the responsibility of management of the organisation to ensure that standards are set throughout
the organisation. Within each department or service, it is the responsibility of managers to ensure that
standards are set for the particular department. This requires co-ordination with the organisation's
steering committee. Departmental managers use available data and information to identify priority
areas for quality monitoring and improvement.
10.8.1 Criteria
10.8.1.1. There is a written quality improvement programme for the general medical and surgical service that is
developed and agreed upon by the personnel of the service.
10.8.1.2. There is a strategy/structure to support the implementation of the quality improvement programme.
10.8.1.3. Indicators of performance are identified to evaluate the quality of treatment and patient care.
10.8.1.4. Processes are selected in order of priority for evaluation and improvement in the quality of treatment
and care.
10.8.1.5. The quality improvement cycle includes the monitoring and evaluation of the standards set, and
remedial action implemented.
10.8.1.6. A documentation audit system is in place.
10.8.1.7. A system for the monitoring of negative incidents is available, which includes the documentation of
interventions and responses to recorded incidents.
10.9. Patient rights

10.9.1 Criteria
10.9.1.1. There are processes that support patient and family rights during care.
10.9.1.2. There are processes to ensure that care is respectful of the patient's personal values and beliefs.
10.9.1.3. Measures are taken to protect the patient's privacy, person and possessions.
10.9.1.4. Staff respect the rights of patients and families to treatment and to refuse treatment.
10.9.1.5. The right of a patient to health education is recognised.
10.9.1.6. Patients are informed of their right to donate human tissue or participate in research.

10.9.1.7. There is a clearly defined process for obtaining consent.
10.10. Prevention and control of infection

10.10.1. There is a comprehensive infection prevention and control programme
encompassing both patient care and employee health.
10.10.1 Criteria
10.10.1.1. There is a programme, which is implemented, to reduce the risks of nosocomial infections in patients
and healthcare workers.
10.10.1.2. The department identifies the procedures and processes associated with the risk of infection, and
implements strategies to reduce risk.
10.10.1.3. Individuals who collect specimens are trained in the proper collection and handling of microbiological
specimens.
10.10.1.4. The department participates in the overall programme for quality management and improvement of
infection control.
10.10.1.5. The department provides education on infection control practices to staff, doctors, patients and, as
appropriate, family and other caregivers.
10.11. Occupational health and safety

10.11.1. The organisation directs and controls risk management programmes, which
include health and safety programmes that comply with legislation.
10.11.1 Criteria
10.11.1.1. The Health and Safety representative for the service supervises the implementation of the health and
safety programme.
10.11.1.2. There is a programme for the inspection of patient care buildings and a plan to reduce fire risks for
the protection of patients, staff and visitors.
10.11.1.3. There is a plan to respond to likely community emergencies, epidemics and other disasters.
10.11.1.4. There is a procedure for the handling, storage and disposal of clinical waste.
10.11.1.5. There is a plan that is implemented for the safeguarding and protection of buildings, patients, staff
and visitors.
10.11.1.6. All staff are trained regarding their role in providing a safe and secure patient care facility.
10.11.1.7. There is a policy and procedure for the monitoring of data on incidents, injuries and other events that
support planning and further risk reduction.

11.Medical Care
Overview of Medical Care

co-ordination.
Continuity of care
organisation.

Standards

patient's care.
Intent of 11.1.1
11.1.1 Criteria
other staff.

providers.
Intent of 11.1.2
complex.
The patient's record contains a history of all care provided by the multidisciplinary team and is made
11.1.2 Criteria
11.1.2.8. The date of each patient record can be identified.

11.2.1. All patients cared for by the organisation have their healthcare needs
Intent of 11.2.1

provided.
11.2.1 Criteria
ongoing care.
assessments.
unwanted variation.
Intent of 11.2.2
Practice guidelines provide a means to improve quality, and assist practitioners and patients in making
11.2.2 Criteria

Intent of 11.2.3
11.2.3 Criteria

Intent of 11.2.4
necessary.
Certain patients may require a modified assessment, eg very young patients, the frail or the elderly,
those terminally ill or in pain, patients suspected of drug and/or alcohol dependency, and victims of
abuse and neglect. The assessment process is modified in accordance with local laws and
regulations, the culture of the patient population, and involves the family when appropriate.
11.2.4 Criteria

Intent of 11.2.5
condition.
11.2.5 Criteria

policy.

Intent of 11.2.6
11.2.6 Criteria
patient's care.
11.3. Patient care

the ward.
Intent of 11.3.1
oxygen and vacuum supply, there are mobile oxygen and vacuum pumps. All necessary fittings for
oxygen and suction are in place and are working satisfactorily. Each bed is serviced by at least one
electrical socket outlet. Each ward is provided with a socket outlet that is connected to the emergency
power supply.

• ECG monitor
• CPR board
• Suction
• Oral airways
• appropriate facilities for intravenous therapy and drug administration (including paediatric sizes);
• drugs for cardiac and respiratory arrest, coma, fits and states of shock (including paediatric doses);
11.3.1 Criteria
record.
Intent of 11.3.2
11.3.2 Criteria



Intent of 11.3.3
context of their personal, cultural and religious beliefs, and
staff are made aware of the unique needs of patients at the end of life. These needs include
treatment of primary and secondary symptoms; pain management; response to the psychological,
social, emotional, religious and cultural concerns of the patient and family; and involvement in care
decisions.
11.3.3 Criteria
management of pain.
pain management.
Intent of 11.3.4

11.3.4 Criteria
11.3.4.2. Policies and procedures guide the care of emergency patients including antenatal, intra-partum and
neonatal complications in obstetric patients).
damaged container).
11.3.5. Risks, benefits, potential complications and care options are discussed with
Intent of 11.3.5
discussed.
The organisation lists all those procedures, which require written, informed consent. Leaders
document the processes for the obtaining of informed consent.

11.3.5 Criteria
11.3.5.3. Patients are informed about their condition and the proposed treatment.
consent.
11.4. Medication
regulations.
Intent of 11.4.1
to prescribe or order medications. Requirements for the documentation of medications ordered or
prescribed and for the use of verbal medication orders are defined in policy.
11.4.1 Criteria
patient care unit.
individuals.

11.4.2. Medications are safely administered.

Intent of 11.4.2
Only staff who is suitably trained and experienced may administer medication to patients. The
The patient, physician, nurse and other care providers work together to monitor patients on
medications. The purposes of monitoring are to evaluate the response to medication, adjust the
dosage or type of medication when needed, and to evaluate the patient for adverse effects.
staff training.
11.4.2 Criteria
medications.

Intent of 11.4.3
11.4.3 Criteria
11.4.3.1. Medication is stored in a locked storage devise or cabinet that is accessible only to authorised staff.
authorised staff have keys.
humidity.
date.

11.5.1. Food, and nutrition therapy appropriate for the patient and consistent with his
Intent of 11.5.1
11.5.1 Criteria

record
Intent of 11.6.1
Education is focused on the specific knowledge and skills that the patient and his or her family will
Education is provided to support the care decisions of patients and families. In addition, when a
patient or family directly participate in providing care, for example changing dressings, feeding and
identified, and, when possible, ongoing relationships are established.
11.6.1 Criteria
equipment, or diet and food interactions.

preferences.
Intent of 11.6.2
11.6.2 Criteria

Intent of 11.7.1
11.7.1 Criteria
11.7.1.3. Continuity and co-ordination is evident throughout all phases of patient care.

Intent of 11.7.2
11.7.2 Criteria

11.7.2.2. The transfer process addresses who is responsible during transfer;

11.7.2.3. The transfer process addresses the transfer of responsibility to another provider or setting, and
transferred.
organisation.
11.7.2.14. The healthcare organisation or other internal unit agreeing to receive the patient, is noted in the
patient's record.

Intent of 11.7.3
11.7.3 Criteria
11.7.3.6. Patients, and, as appropriate, their families, are given understandable follow-up instructions in writing
at referral or discharge.
care.
11.7.4. A discharge summary is written for each patient and is made available in the
patient's record.
Intent of 11.7.4
11.7.4 Criteria
11.7.4.1. A discharge summary is written by the medical practitioner, at the discharge of each patient.


11.7.4.12. When appropriate, the patient is given a copy of the discharge summary.

medical service.
Intent of 11.8.1
organisation's steering committee. Departmental managers use available data and information to
identify priority areas for quality monitoring and improvement.
11.8.1 Criteria
11.8.1.1. There is a written quality improvement programme for the medical service that is developed and
agreed upon by the personnel of the service.
and care.

11.9.1 Criteria
11.9.1.6. Patients are informed of their right to donate human tissue or to participate in research.

11.10.1 Criteria

specimens.
infection control.

11.11.1 Criteria
11.11.1.1. The Health and Safety representative for the service directs the implementation of the health and
safety programme.
11.11.1.3. There is plan to respond to likely community emergencies, epidemics and other disasters.
and visitors.


12.Surgical Care
Overview of Surgical Care

co-ordination.
carry out these activities. Each provider has a clear role in patient care. Credentialling, registration,
Continuity of care
organisation.

Standards

patient's care.
Intent of 12.1.1
12.1.1 Criteria
other staff.

providers.
Intent of 12.1.2
complex.
available to all relevant care givers who are authorised to have access to its content.
12.1.2 Criteria

Intent of 12.2.1

provided.
12.2.1 Criteria
ongoing care.
assessments.
unwanted variation.
Intent of 12.2.2
12.2.2 Criteria

Intent of 12.2.3
12.2.3 Criteria
12.2.4. Each patient has an initial assessment which complies with current policies,

Intent of 12.2.4
social assessment, particularly when the patient and his or her family will be responsible for the cost of
all or a portion of the care.
necessary.
12.2.4 Criteria
12.2.4.1. Each patient admitted has an initial assessment which meets organisation policy.

Intent of 12.2.5
condition.
12.2.5 Criteria

policy.

Intent of 12.2.6
12.2.6 Criteria
patient's care.
12.3. Patient care

the ward.
Intent of 12.3.1
There is at least one oxygen and one vacuum point for every 2 beds. Where there is no piped oxygen
and vacuum supply, there are mobile oxygen and vacuum pumps. All necessary fittings for oxygen
and suction are in place and working satisfactorily. Each bed is serviced by at least one electrical
socket outlet. Each ward is provided with a socket outlet which is connected to the emergency power
supply.

• ECG monitor
• CPR board
• Suction
• Oral airways
12.3.1 Criteria
record.
Intent of 12.3.2
of the organisation, and train staff to use them.
12.3.2 Criteria



Intent of 12.3.3
context of their personal, cultural and religious beliefs; and
decisions.
12.3.3 Criteria
management of pain.
pain management.
Intent of 12.3.4

12.3.4 Criteria
damaged container).
12.3.4.6. Policies and procedures guide the care of patients with communicable diseases and immuno-
suppressed patients.
Intent of 12.3.5
consent. Designated staff are trained to inform patients and to obtain and document patient consent.
discussed.
The organisation lists all those procedures which require written, informed consent. Leaders

12.3.5 Criteria
12.3.5.14. The information provided is recorded together with the record of the patient having provided written or
verbal consent.

care.
Intent of 12.3.6
12.3.6 Criteria

Intent of 12.3.7
12.3.7 Criteria
12.4. Medication

regulations.
Intent of 12.4.1
12.4.1 Criteria
patient care unit.
individuals.

Intent of 12.4.2
The patient, physician, nurse, and other care providers work together to monitor patients on
staff training.
12.4.2 Criteria
medications.



Intent of 12.4.3
12.4.3 Criteria
humidity.
date.

Intent of 12.5.1
12.5.1 Criteria
12.5.1.7. Nutrition therapy provided is written in the patient's record.


record.
Intent of 12.6.1
Education is focused on the specific knowledge and skills the patient and his or her family will need to
make care decisions, participate in care, and continue care at home.
family directly participate in providing care, for example changing dressings, feeding and
12.6.1 Criteria
preferences.
Intent of 12.6.2
12.6.2 Criteria

Intent of 12.7.1
12.7.1 Criteria

Intent of 12.7.2
12.7.2 Criteria
transferred.
organisation.
12.7.2.13. The condition of the patient before transfer.
12.7.2.14. The healthcare organisation, or other internal unit agreeing to receive the patient, is noted in the
patient's record.

Intent of 12.7.3

12.7.3 Criteria
care.
patient's record.
Intent of 12.7.4
12.7.4 Criteria
12.7.4.1. A discharge summary is written by the medical practitioner, at discharge of each patient.
12.7.4.3. The summary contain the reason for admission.

surgical service.
Intent of 12.8.1
12.8.1 Criteria
12.8.1.1. There is a written quality improvement programme for the surgical service that is developed and

and care.

12.9.1 Criteria

12.10.1 Criteria
specimens.
infection control.

12.11.1 Criteria
12.11.1.1. The Health and Safety representative for the service supervises implementation of the health and
safety programme.
and visitors.


13.Critical Care
Overview of Critical Care

co-ordination.
curative, or rehabilitative and may include the use of anaesthesia, surgery, medication, supportive
Continuity of care
organisation.

Standards

patient's care.
Intent of 13.1.1
13.1.1 Criteria
other staff.

providers.
Intent of 13.1.2
complex.
13.1.2 Criteria
13.1.2.8. The date of each patient record can be identified.

Intent of 13.2.1

provided.
13.2.1 Criteria
13.2.1.1. The organisation provides policies and procedures for assessing patients on admission, and during
ongoing care.
assessments.
unwanted variation.
Intent of 13.2.2
the criteria established by the leaders and are adapted to the community, patient needs, and
13.2.2 Criteria

Intent of 13.2.3
13.2.3 Criteria

Intent of 13.2.4
necessary.
13.2.4 Criteria
13.2.4.14. A process is in place to identify needs for discharge/transfer planning at the initial assessment.

Intent of 13.2.5
condition.
13.2.5 Criteria

13.2.5.6. If surgery is to be performed, a note must be made in the patient's record, in accordance with a
written policy.

Intent of 13.2.6
13.2.6 Criteria
patient's care.
13.3. Patient care

the critical care unit.
Intent of 13.3.1
Professional guidelines for critical care services recommend the staff and resources required to
manage the service safely. The staff in the ward are in possession of these guidelines, and ensure
that the recommendations are implemented. In South Africa the South African Society of
Anaesthesiologists publishes these guidelines. These guidelines provide norms for staffing a critical
care unit, and also for the services and facilities required.
13.3.1 Criteria
13.3.1.1. Current guidelines for the provision of critical care services and facilities are followed.
13.3.1.2. Staffing of the service complies with accepted staffing norms for critical care services.
13.3.1.3. Available medical equipment complies with accepted norms for critical care services.
13.3.1.5. Where resuscitation, intensive care, life support or critical monitoring equipment is used that does not
have built-in battery backup units, there is an uninterruptable power supply (UPS) that complies with
relevant requirements and regularly serviced and tested.

record.
Intent of 13.3.2
13.3.2 Criteria

Intent of 13.3.3

decisions.
13.3.3 Criteria
management of pain.
pain management.
Intent of 13.3.4
13.3.4 Criteria
damaged container).


13.3.5. The risks, benefits, potential complications and care options are discussed
with the patient and his or her family or with those who make decisions for the patient.
Intent of 13.3.5
discussed.
13.3.5 Criteria
verbal consent.


care.
Intent of 13.3.6
13.3.6 Criteria

Intent of 13.3.7
13.3.7 Criteria
13.4. Medication
regulations.
Intent of 13.4.1
13.4.1 Criteria
patient care unit.
13.4.1.3. The use of verbal medication orders is stated.

individuals.

Intent of 13.4.2
staff training.
13.4.2 Criteria
medications.

Intent of 13.4.3
13.4.3 Criteria
humidity.

date.

Intent of 13.5.1
13.5.1 Criteria

Intent of 13.6.1
Patients are most frequently transferred from the critical care unit to a high care or step down unit
before discharge. Without co-ordination and effective transfer of information and responsibilities, errors
of omission and commission may occur, exposing the patient to avoidable risks. A transfer summary is
one of the most important documents to ensure continuity of care and facilitate correct management.
13.6.1 Criteria
13.6.1.5. A transfer summary is written for each patient and is made available in the patient's record.


13.6.1.12. The summary contains the patient's condition at transfer.

Intent of 13.6.2
13.6.2 Criteria
transferred.
13.6.2.9. When transferred to another organisation, the receiving organisation is given a written summary of
the patient's clinical condition and the interventions provided by the referring organisation.
13.6.2.11. The following are noted in patient's record: the reason(s) for the transfer.
13.6.2.12. The following are noted in patient's record: any special conditions related to transfer.
13.6.2.13. The following are noted in patient's record: the condition of the patient before transfer.
13.6.2.14. The following are noted in patient's record: the healthcare organisation or other internal unit agreeing
to receive the patient.

critical care service.
Intent of 13.7.1
13.7.1 Criteria
13.7.1.1. There is a written quality improvement programme for the critical care service that is developed and

and care.

13.8.1 Criteria

13.9.1 Criteria
specimens.
infection control.

13.10.1 Criteria
safety programme.
and visitors.


14.Obstetric/Maternity Care
Overview of Obstetric/Maternity Care

co-ordination.
policies or job descriptions determine that role. The patient, the family or other trained caregivers may
carry out some of this care.
Continuity of care
organisation.

Standards

patient's care.
Intent of 14.1.1
are identified in the patient's record or in a manner that is made known to the staff. In the
obstetric/maternity unit care providers are identified for the antenatal ward, labour ward, neonatal
nursery, and postnatal ward. A qualified midwife or medical practitioner is present at every birth.
Specialists are available in emergencies, either maternal or neonatal.
14.1.1 Criteria
other staff.
14.1.1.4. The requirements of antenatal, labour and postnatal wards and nurseries are individually included in
the staffing requirements.
14.1.1.5. A registered midwife and/or medical practitioner is present at every birth.
14.1.1.6. Specialists are available for consultation.
14.1.1.7. At least one person is available at all times who is qualified (medical practitioner or advanced
midwife) in the management of maternal and neonatal emergencies.

providers.
Intent of 14.1.2
complex.
14.1.2 Criteria


Intent of 14.2.1
provided.
14.2.1 Criteria
ongoing care.
assessments.
unwanted variation.
Intent of 14.2.2
14.2.2 Criteria
14.2.2.3. The maternal and fetal conditions and the progress of labour are recorded on a partogram in every
labour.
14.2.2.4. Criteria are available for referral of complicated labour.

Intent of 14.2.3

14.2.3 Criteria
Intent of 14.2.4
Patients' social, cultural and family status is important factors that can influence their response to
social assessment, particularly when the patient and her family will be responsible for the cost of all or
a portion of the care.
necessary.
A history of the antenatal care in progress is available.
The onset and progress of labour are recorded.
14.2.4 Criteria
14.2.4.2. The initial assessment includes antenatal history.
14.2.4.3. The initial assessment includes maternal and fetal examination.
14.2.4.9. The assessment identifies patients in pain.

Intent of 14.2.5
condition.

14.2.5 Criteria
surgical, gynaecological or obstetric policy.

Intent of 14.2.6
assessment findings and to combine this information into a comprehensive picture of her condition.
From this collaboration, the patient's needs are identified, the order of their importance is established,
and care decisions are made.
14.2.6 Criteria
patient's care.
14.2.6.3. Patient needs are prioritised based on assessment results.
14.2.6.4. The patient and/or her family participate in the decisions regarding the priority needs to be met.
14.3. Patient care

the ward.
Intent of 14.3.1
The delivery room has an appropriate delivery table.
Each delivery room has:
o at least one cardiotocograph machine;
o an infant warming and resuscitation cart;
o an incubator with adjustable temperature and separate oxygen supply;
o a fetal monitor;
o equipment for inhalation analgesia.
There is a nursery which is temperature controlled and has:
o suitable bassinettes;

o phototherapy lights;
o a panel for the viewing of babies.
There is milk kitchen dedicated to infant feeding which has:

• a fridge dedicated for milk feeds;
• washing-up facilities dedicated to the preparation of infant feeds.
oxygen and suction are in place and working satisfactorily. Each bed is serviced by at least one
power supply.
• ECG monitor
• CPR board
• Suction
• Oral airways
• Tracheotomy sets where there is no theatre
14.3.1 Criteria
14.3.1.5. Where there is no piped oxygen installations, there is a documented procedure for ensuring that
14.3.1.8. There is a dedicated area for the preparation of infant feeds.
record.
Intent of 14.3.2

14.3.2 Criteria
14.3.3. Compassionate care is provided to those in pain.

Intent of 14.3.3
14.3.3 Criteria
management of pain.
pain management.
Intent of 14.3.4

needs. A variety of services are considered "high-risk" because of the complex equipment needed to
treat a life-threatening condition, the nature of the treatment, or the potential for harm to the patient.
• availability and use of resuscitation equipment.
14.3.4 Criteria
14.3.4.2. Policies and procedures guide the management of major complications (antenatal, intra-partum and
neonatal).
damaged container).
14.3.4.7. Policies and procedures guide the management of meconium-stained liquor.
14.3.4.8. Policies and procedures guide performing of episiotomies.
14.3.4.9. Policies and procedures guide Apgar scoring and evaluation.
Intent of 14.3.5
Every woman receives adequate objective information relating to methods of delivery which allow her
to make an informed choice. Women are fully informed on matters relating to their care at each stage
of labour and are involved in decision-making relating to their care.
14.3.5 Criteria
14.3.5.3. Patients are informed about methods of delivery.
14.3.5.4. Patients are informed about potential benefits and drawbacks to the proposed methods.


verbal consent.

care.
Intent of 14.3.6
14.3.6 Criteria
14.3.6.1. The surgical procedure to deliver the baby is documented.
14.3.6.2. The date and time of the delivery is documented.

Intent of 14.3.7
14.3.7 Criteria
14.3.7.1. The physiological status of mother and infant is monitored during the immediate post-surgery period.
14.4. Medication
regulations.
Intent of 14.4.1
Medications brought into the organisation by the patient or her family are known to the patient's
physician and noted in the patient's record.
14.4.1 Criteria

patient care unit.
individuals.
14.4.1.7. Medications brought into the organisation by the patient or her family are known to the patient's

Intent of 14.4.2
staff training.
14.4.2 Criteria
medications.

Intent of 14.4.3
14.4.3 Criteria


humidity.
date.

14.5.1. Food and nutrition therapy appropriate for the patient and consistent with her
clinical care is regularly available.
Intent of 14.5.1
14.5.1 Criteria

14.6.1. Each patient's educational needs are assessed and written in her record.
Intent of 14.6.1
Education is focused on the specific knowledge and skills the patient and her family will need to make
care decisions, participate in care, and continue care at home.

14.6.1 Criteria
14.6.1.3. Patients and families learn about breastfeeding.
14.6.1.4. Patients and families learn about postnatal contraception.
14.6.1.5. Patients and families learn about care of the newborn.
preferences.
Intent of 14.6.2
14.6.2 Criteria

Intent of 14.7.1
14.7.1 Criteria

Intent of 14.7.2
The process for transferring the patient must consider transportation needs. The qualifications of the
individual accompanying the patient must be appropriate.

14.7.2 Criteria
transferred.
organisation.
patient's record.

Intent of 14.7.3
14.7.3 Criteria
at discharge.
care.
patient's record.
Intent of 14.7.4
14.7.4 Criteria
14.7.4.3. The summary contains the mother's condition on admission.
14.7.4.4. The summary contains the significant findings during labour.

14.7.4.5. The summary contains the date and time of delivery.

14.7.4.6. The summary contains the maternal and fetal conditions after delivery.
14.7.4.9. The summary contains the condition of mother and baby at discharge.

obstetric service.
Intent of 14.8.1
14.8.1 Criteria
14.8.1.1. There is a written quality improvement programme for the obstetric service that is developed and
and care.

14.9.1 Criteria
14.9.1.3. Measures are taken to protect a patient's privacy, person and possessions.
14.9.1.6. Patients are informed of their right to donate human tissue or participate in research.


14.10.1 Criteria
specimens.
infection control.

14.11.1 Criteria
safety programme.
and visitors.


15.Psychiatric Care (Ward)
Overview of Psychiatric Care (Ward)

co-ordination.
curative or rehabilitative and may include the use of medication, supportive therapies, or a combination
of these. A plan of care is not sufficient to achieve optimal outcomes unless the delivery of the
services is co-ordinated, integrated and monitored.
Continuity of care
organisation.
Processes for continuity and co-ordination of care among psychiatrists and medical practitioners,
nurses and other health care providers must be implemented in and between all services.

Standards

patient's care.
Intent of 15.1.1
The individuals who bear overall responsibility for the patient's care or particular phase of care are
identified in the patient's record or in a manner that is made known to the staff.
15.1.1 Criteria
other staff.

providers.
Intent of 15.1.2
complex.
15.1.2 Criteria

Intent of 15.2.1

provided.
15.2.1 Criteria
ongoing care
assessments.
unwanted variation.
Intent of 15.2.2
clinical decisions. Regardless of the source, the scientific basis of guidelines should be reviewed and
approved by organisation leaders and clinical practitioners before implementation. This ensures that
they meet the criteria established by the leaders and are adapted to the community, patient needs and
15.2.2 Criteria
15.2.2.4. Guidelines are reviewed and adapted on a regular basis after implementation

Intent of 15.2.3
15.2.3 Criteria

Intent of 15.2.4
necessary.
15.2.4 Criteria
15.2.5. Pre-anaesthetic assessments are documented.

Intent of 15.2.5
Psychiatric patients sometimes receive anaesthesia for electro-convulsive therapy.
planned anaesthetic. The clinical assessment and results of investigations must be available to the
doctor performing the assessment.
15.2.5 Criteria
15.2.5.1. Patients have a medical assessment performed before surgery or any invasive procedure e.g. bone
marrow aspiration, lumbar puncture etc. under anaesthetic.



Intent of 15.2.6
15.2.6 Criteria
patient's care.
15.3. Patient care

the service.
Intent of 15.3.1
supply.
• ECG monitor
• CPR board
• Suction
• Oral airways


15.3.1 Criteria
cylinder pressures (i.e contents) are constantly monitored while patients are receiving oxygen.
record.
Intent of 15.3.2
15.3.2 Criteria
15.3.2.4. All procedures and diagnostic tests ordered and performed, are written into the patient's record.
15.3.3. Each patient participates in a structured treatment plan.

Intent of 15.3.3
Each patient has psychotherapeutic interviews with an appropriately qualified person to meet his/her
needs.
There is a structured therapeutic environment which allows for group therapy, occupational therapy, or
music or art therapy as required by individual patients.
15.3.3 Criteria
15.3.3.1. There is evidence of regular psychotherapeutic interviews as indicated by the programme and
individual patient's needs.
15.3.3.2. There is documented participation in a structured therapeutic programme six to seven hours per day.
15.3.3.3. There is a range of therapeutic activities available, according to the identified needs of the patient.
15.3.3.4. There is documented participation of the patient with his or her family or significant other(s) in group
therapy, as appropriate.
15.3.3.5. The patient has the least restrictive environment possible according to policy, with any restrictions
placed upon him/her written into the treatment plan.

Intent of 15.3.4
decisions.
15.3.4 Criteria
management of pain.
pain management.
Intent of 15.3.5
needs. Psychiatric patients are commonly in this group as they may not speak for themselves,
understand the care process or participate in decisions regarding their care.
Policies and procedures are important for staff to understand high-risk patients and services, and to

15.3.5 Criteria
15.3.5.3. Policies and procedures guide the management of patients in restraint.
15.3.5.4. Policies and procedures guide the management of patients who may be a danger to themselves or
others.
15.3.5.5. Policies and procedures guide management of the violent patient.
15.3.5.6. Policies and procedures guide management of the detoxification stage of treatment.
15.3.5.8. Policies and procedures guide the administration of electroconvulsive therapy.
15.3.5.9. Policies and procedures guide the management of patients in seclusion.
15.3.5.10. Policies and procedures guide observation of patients treated for eating disorders.
15.3.6. Risks,benefits, potential complications and care options are discussed with
sthe patient and his or her family or with those who make decisions for the patient.
Intent of 15.3.6
discussed.

15.3.6 Criteria
15.3.6.9. There is a written policy guiding the consent for HIV testing which is specific to patients in psychiatric
hospitals.
15.3.6.12. The information is provided to patients in a clear and understandable way..
consent.
15.3.7 Criteria
hospitals.
15.3.7.10. Patients know the identity of the psychiatrist or other practitioner responsible for their care.
consent.
15.4. Medication
regulations.

Intent of 15.4.1
experience, and who are permitted by law, registration, or regulations to prescribe or order
prescribed, and using verbal medication orders is defined in policy.
15.4.1 Criteria
patient care unit.
individuals.
15.4.1.7. Medication brought into the organisation by the patient or his or her family are known to the patient's
physician and noted in the patients record.

Intent of 15.4.2
staff training.
15.4.2 Criteria
medications.


15.4.2.10. Medications prescribed and administered are recorded for each patient.

Intent of 15.4.3
Patient care units store medications in a clean and safe environment that complies with law,
regulation, and professional practice standards.
15.4.3 Criteria
humidity.
date.

Intent of 15.5.1
15.5.1 Criteria

15.6.1. Each patient's educational needs are assessed and written in their record.

Intent of 15.6.1
15.6.1 Criteria
preferences.
Intent of 15.6.2
15.6.2 Criteria

Intent of 15.7.1

15.7.1 Criteria

Intent of 15.7.2
15.7.2 Criteria
transferred.
organisation.
patient's record.

Intent of 15.7.3
15.7.3 Criteria


care.
patient's record.
Intent of 15.7.4
15.7.4 Criteria
15.7.4.1. A discharge summary is written by the medical practitioner, on the discharge of each patient.

psychiatric service.
Intent of 15.8.1
15.8.1 Criteria
15.8.1.1. There is a written quality improvement programme for the psychiatric service that is developed and
and care.


15.9.1 Criteria

15.10.1 Criteria
specimens.
infection control.

15.11.1 Criteria
safety programme.
and visitors.


16.Paediatric Care
Overview of Paediatric Care

co-ordination.
Continuity of care
organisation.
Infants and children have very special needs. These needs relate to a bright, stimulating and non-
threatening environment.

Standards

16.1.1. During all phases of care, there is a qualified individual identified as
Intent of 16.1.1
The individual who bears overall responsibility for the patient's care or for a particular phase of care is
16.1.1 Criteria
16.1.1.1. The individual responsible for the patient's care is designated.
16.1.1.2. The individual responsible for the patient's care is qualified.
16.1.1.3. The individual responsible for the patient's care is identified and made known to the patient and other
staff.

providers.
Intent of 16.1.2
complex.
16.1.2 Criteria

Intent of 16.2.1
When a patient enters a ward, the specific information required and the procedures for obtaining and
documenting it depend on the patient's needs and on the setting in which care is being provided.

16.2.1 Criteria
ongoing care.
assessments.
unwanted variation.
Intent of 16.2.2
16.2.2 Criteria

Intent of 16.2.3
16.2.3 Criteria
16.2.3.4. The findings of assessments performed outside the organisation are verified at admission.

Intent of 16.2.4
necessary.
Certain patients may require a modified assessment, e.g. very young patients, those terminally ill or in
pain, and victims of abuse and neglect. The assessment process is modified in accordance with local
laws and regulations, the culture of the patient population, and involves the family when appropriate.
16.2.4 Criteria

Intent of 16.2.5
The preoperative anaesthetic assessment determines if the patient is a good candidate for the
In an emergency, the initial assessment may be limited to the patient's apparent needs and condition.

16.2.5 Criteria


policy.
16.2.5.7. All patients are reassessed at appropriate intervals to determine their response to care and treatment,
and to plan for continued treatment or discharge.

Intent of 16.2.6
16.2.6 Criteria
patient's care.
16.3. Patient care

the paediatric service.
Intent of 16.3.1
all times, treatment and dressing rooms, and adequate storage space for clean linen. Beds in the
paediatric service are suitable for the ages of the children. Cleaning equipment is safely stored in a
room or cupboard expressly for this purpose. There are adequate toilet and bathing facilities for the
number of patients in the ward (at least one toilet for every 8 patients, and one bath or shower for
every 12 patients). The size of the toilets is suitable for the ages of the children admitted.
The ward is bright with decorations which will interest the children.
There is a milk kitchen dedicated to infant feeding which has:

§ a fridge dedicated for milk feeds;
§ washing-up facilities dedicated to the preparation of infant feeds.

supply.
• Defibrillator with infant paddles
• ECG monitor
• CPR board
• Suction
• Oral airways
The resuscitation equipment is available paediatric sizes.
• appropriate facilities for intravenous therapy and drug administration (paediatric sizes);
• drugs for cardiac and respiratory arrest, coma, fits and states of shock (paediatric doses);
16.3.1 Criteria
16.3.1.8. There is a milk kitchen dedicated to the preparation of infant feeds.
16.3.2. The care provided to each patient is planned and is written in the patient's
record.
Intent of 16.3.2
Individuals qualified to do so order diagnostic and other procedures.
Orders must be easily accessible if they are to be acted on in a timely manner.
Locating orders on a common sheet or in a uniform location in patient records facilitates the correct
understanding and carrying out of orders.
The method used must respect the confidentiality of patient care information. When guidelines, and
other related tools are available and relevant to the patient population and mission of the organisation,
there is a process to evaluate and adapt them to the needs and resources of the organisation and to

train staff to use them.

16.3.2 Criteria

Intent of 16.3.3
decisions.
16.3.3 Criteria
management of pain.
pain management.
16.3.4. Policies and procedures guide the care of high-risk patients, and the
provision of high-risk services.
Intent of 16.3.4
needs. Children are commonly in this group as they may not speak for themselves, understand the
care process or participate in decisions regarding their care.


Special facilities and safety measures required by children need to be specified. Children who are
hospitalised for long periods may need policies to define their educational needs.
16.3.4 Criteria
16.3.4.2. A collaborative process is used to develop applicable policies and procedures.
damaged container).
16.3.4.7. Policies and procedures guide the care of patients on life-support or who are comatose.
16.3.4.13. Policies and procedures guide security of newborn babies.
the patient and his or her family or those who make decisions for the patient.
Intent of 16.3.5

discussed.
The consent process always concludes with the patient or guardian signing the consent form, or the
documentation of the patient's or guardian's verbal consent in the patient's record by the individual who
provided the information for consent. Documentation includes the statement that the patient or
guardian acknowledged full understanding of the information. The patient's surgeon or other qualified
individual provides the necessary information and the name of this person appears on the consent
form.
16.3.5 Criteria
16.3.5.3. Patients or their guardians are informed about their condition, and the proposed treatment.
16.3.5.4. Patients or their guardians are informed about potential benefits and drawbacks to the proposed
treatment.
16.3.5.5. Patients or their guardians are informed about the possible alternatives to the proposed treatment.
16.3.5.6. Patients or their guardians are informed about the likelihood of successful treatment.
16.3.5.7. Patients or their guardians are informed about possible problems related to recovery.
16.3.5.8. Patients or their guardians are informed about possible results of non-treatment.
16.3.5.14. The information provided is recorded together with the record of the patient or the patient's guardian
having provided written or verbal consent.

care.
Intent of 16.3.6
16.3.6 Criteria
16.3.6.2. A description of the surgical procedure, findings, and any surgical specimens is documented.

after surgery and is written in the patient's record.
Intent of 16.3.7

16.3.7 Criteria
16.4. Medication
regulations.
Intent of 16.4.1
16.4.1 Criteria
patient care unit.
individuals.
16.4.2. Medications are safely administered

Intent of 16.4.2

staff training.
16.4.2 Criteria
medications.

Intent of 16.4.3
16.4.3 Criteria
humidity.
date.

Intent of 16.5.1
16.5.1 Criteria
16.5.1.1. Food, appropriate to the infant or child, is regularly available.

16.5.1.4. When families provide food, they are educated about the child's diet limitations.
16.5.1.9. The hospital implements the principles of Baby Friendly Hospital with regard to breastfeeding.

record.
Intent of 16.6.1
Education is focused on the specific knowledge, age and skills of the patient. The family will need to
Education is provided to support the care decisions of patients and families. In addition, when a
family directly participates in providing care, for example changing dressings, feeding and
16.6.1 Criteria
16.6.1.5. Patients or their guardians are educated about relevant high health risks, e.g. safe use of medication
and medical equipment, or diet and food interactions.
preferences.
Intent of 16.6.2
16.6.2 Criteria


Intent of 16.7.1
16.7.1 Criteria

Intent of 16.7.2
Transfer may be a brief process with the patient alert and talking, or it may involve continuous nursing
or medical supervision. The process for transferring the patient must consider transportation needs.
The qualifications of the individual accompanying the patient must be appropriate.
16.7.2 Criteria
transferred.
organisation.
patient's record.


Intent of 16.7.3
16.7.3 Criteria
16.7.3.6. Patients, and, as appropriate, their families, are given understandable follow-up instruction in writing
16.7.3.7. Follow-up instructions: include any return for follow-up care, and when and where to obtain urgent
care.
patient's record.
Intent of 16.7.4
16.7.4 Criteria

paediatric service.
Intent of 16.8.1

16.8.1 Criteria
16.8.1.1. There is a written quality improvement programme for the paediatric service that is developed and
and care.

16.9.1 Criteria

16.10.1 Criteria
specimens.
infection control.

16.11.1 Criteria
safety programme.

and visitors.

Diagnostic and treatment support services
17.Operating Theatre and Anaesthesia services
Overview of Operating Theatre and Anaesthesia services

Services in the operating theatre and anaesthesia services carry high risk. The collaboration between
staff in the theatre, health and safety staff, infection control, and those responsible for the supply and
maintenance of equipment is essential.
Professional guidelines of must be available to theatre staff, and closely followed.
The organisation ensures that an adequate number of suitably qualified and experienced staff are
available at all times to provide for a safe operating theatre and anaesthetic service.

Standards
17.1. Management of the operating theatre and anaesthetic service

17.1.1. The operating theatre and anaesthetic services are managed and staffed to
provide a safe and effective service.
Intent of 17.1.1
Theatre management staff work with organisation leaders to ensure adequate and suitable
management processes and staffing of the theatre, anaesthetic service, and recovery room.
The qualifications of those persons who administer anaesthesia in the hospital are documented in
accordance with current professional society standards.
17.1.1 Criteria
17.1.1.1. There is a theatre users’ committee, consisting of representatives of, for example, the surgical staff,
the anaesthetic staff, the nursing staff and organisational management, which meet regularly.
17.1.1.2. A senior professional who is suitably qualified and experienced is in charge of the theatre and the
recovery area.
17.1.1.3. Operating theatre rosters ensure that registered nurses with suitable qualifications and experience
are present during all shifts for theatre duties, anaesthetic assistance, and for recovery room duties.
17.1.1.4. Anaesthesia is administered only by medical practitioners who are privileged by the organisation to do
so.
17.1.1.5. Trainee anaesthetists are under the supervision of trained anaesthesiologists.
17.1.1.6. The anaesthetist is directly responsible for only one anaesthetic at a time.
17.1.1.7. Anaesthesia is commenced and terminated only in the presence of a member of the staff whose sole
duty it is to assist the anaesthetist until such time as the latter indicates that assistance is no longer
required.
17.1.1.8. The surgeon performing the procedure(s) is available before the anaesthetist commences
administering the anaesthetic.
17.1.1.9. There is at least one suitably trained and experienced anaesthetic nurse per operating theatre.
17.1.1.10. Nursing staff, who are trained in recovery room care, are available until the patient has fully
recovered.
17.1.2. Policies and procedures are developed, relating to the activities in the
operating theatre and anaesthetic services.
Intent of 17.1.2
Policies and procedures are necessary to guide the administration of the operating theatre and
anaesthetic services to ensure the smooth operation of those services, and to ensure that staff act
swiftly and in a co-ordinated manner in an emergency. Those policies and procedures are made
available to all theatre, recovery room and anaesthetic staff, and are known and implemented.
Biohazards, which need to be monitored and notified, include radiation, laser and electrical hazards.
17.1.2 Criteria
17.1.2.1. There are written policies and procedures to guide the activities of the theatre and anaesthetic
services.
17.1.2.2. Policies and procedures relate to the duties of the theatre and recovery room nursing staff.
17.1.2.3. Policies and procedures relate to theatre cleaning.
17.1.2.4. Policies and procedures relate to the notification of biohazards.
17.1.2.5. Policies and procedures relate to drug control.
17.1.2.6. Policies and procedures relate to patient positioning.

17.1.3. Policies and procedures are developed relating to the preparation of patients
for surgery.
Intent of 17.1.3
Policies and procedures are available, to ensure that informed consent is documented, the correct
patient is identified, and the the correct nature of and the site for surgery are documented. Processes
during the surgery, such as the use of instruments and counting procedures, are documented, to
ensure co-ordination and safety.
17.1.3 Criteria
17.1.3.1. Policies and procedures relating to the preparation of patients for surgery include scheduling of
patients for listed and emergency surgical procedures.
17.1.3.2. Policies and procedures relating to the preparation of patients for surgery include patient
identification.
17.1.3.3. Policies and procedures relating to the preparation of patients for surgery include verification of the
nature and site of the operation.
17.1.3.4. Policies and procedures relating to the preparation of patients for surgery include verification of the
last oral intake.
17.1.3.5. Policies and procedures relating to the preparation of patients for surgery include checking of consent
documents.
17.1.3.6. Policies and procedures relating to the preparation of patients for surgery include specifying the
instruments required for specific operations.
17.1.3.7. Policies and procedures relating to the preparation of patients for surgery include aseptic techniques.
17.1.3.8. Policies and procedures relating to the preparation of patients for surgery include the intra-operative
recording required.
17.1.3.9. Policies and procedures relating to the preparation of patients for surgery include the recording of
tissue(s) and specimen(s) collected.
17.1.3.10. Policies and procedures relating to the preparation of patients for surgery include counting
procedures for swabs, instruments and needles, and procedures to be adopted in the event of
incorrect counts.
17.1.4. Policies and procedures are developed relating to the anaesthetic service.
Intent of 17.1.4
Guidelines of professional societies and associations are available and followed whenever
anaesthesia is administered. This includes nursing staff, who assist the anaesthetist and who monitor
the recovery of patients. Implementing these guidelines is particularly important with regard to the
qualifications, training and experience required by staff members in the service, and also the provision,
maintenance and use of medical equipment and drugs.
Controlling bodies also develop guidelines and regulations relating to professional practice.
17.1.4 Criteria
17.1.4.1. Policies and procedures relating to the anaesthetic service include the required qualifications of
persons who administer anaesthetics and of persons who assist the anaesthetist.
17.1.4.2. Policies and procedures relating to the anaesthetic service include anaesthetic equipment hazards.
17.1.4.3. Policies and procedures relating to the anaesthetic service include the use of scavenging equipment
for the removal of various vapours and waste anaesthetic gases.
17.1.4.4. Policies and procedures relating to the anaesthetic service include the pre-operative assessment and
pre-medication.
17.1.4.5. Policies and procedures relating to the anaesthetic service include assessing the fitness of patients,
to leave the recovery area.
17.1.4.6. There are guidelines relating to the administration of major regional anaesthesia.
17.1.4.7. There are guidelines relating to the use of conscious sedation, where applicable.
17.1.4.8. Policies and procedures comply with current guidelines of the professional society of
anaesthesiologists.

17.2. Anaesthetic care

17.2.1. A pre-anaesthetic assessment is conducted and recorded.
Intent of 17.2.1
Because anaesthesia carries a high level of risk, its administration is carefully planned. The patient's
pre-anaesthetic assessment is the basis for that plan and for the use of post-operative analgesia.
The pre-anaesthetic assessment provides information needed to:
• select the type of anaesthesia to be administered and plan anaesthetic care;
• identify any drug sensitivities;
• safely administer the appropriate anaesthetic; and
• interpret the findings of patient monitoring.
An anaesthesiologist or other qualified individual conducts the pre-anaesthetic assessment.
Anaesthetic care is carefully planned and documented in the anaesthetic record. The plan considers
information from other patient assessments and identifies the anaesthetic to be used, the method of
administration, other medications and fluids, monitoring procedures, and anticipated post-anaesthetic
care.
The anaesthetic planning process includes education of the patient and his or her family or decision-
maker regarding the risks, potential complications, and options related to the planned anaesthesia and
postoperative analgesia. This discussion occurs as part of the process to obtain consent for
anaesthesia. The anaesthesiologist or the qualified individual who will administer the anaesthetic
provides this education.
17.2.1 Criteria
17.2.1.1. Patients have an anaesthetic assessment performed before the administration of anaesthesia.
17.2.1.2. A qualified individual conducts the pre-anaesthetic assessment of each patient.
17.2.1.3. The medical assessment of surgical patients is documented before the start of the anaesthesia.
17.2.1.4. The anaesthetic assessment determines if the patient is an appropriate candidate for the planned
anaesthesia.
17.2.1.5. The anaesthetic assessment identifies any drug sensitivities.
17.2.1.6. Patients are re-evaluated before the induction of anaesthesia.
17.2.1.7. The anaesthetic care of each patient is planned.
17.2.1.8. The plan is documented.
17.2.1.9. The patient, family and decision-makers are educated regarding the risks and, potential complications
of, and options related to the anaesthesia.
17.2.1.10. The anaesthesiologist or other qualified individual provides that education.
17.2.2. Each patient’s physiological status is monitored during anaesthesia and

surgery, and recorded.
Intent of 17.2.2
The anaesthetist monitors and records the physiological status of the patient during anaesthesia, and
enters the drugs and intravenous fluids used, and the anaesthetic, in the patient's anaesthetic record.
The anaesthetist has access to the patient care notes, and is familiarised with the findings of the
medical examination. It is important that each health professional has access to the records of other
care providers, in accordance with organisational policy.

17.2.2 Criteria
17.2.2.1. The patient’s physiological status is continuously monitored during the anaesthesia and surgery.
17.2.2.2. The results of such monitoring are entered into the patient’s record.
17.2.2.3. The anaesthetic used is entered into the patient’s anaesthetic record.
17.2.2.4. Patient care notes are available to the anaesthesiologist.
17.2.3. There is a system to monitor and document each patient’s post-anaesthetic

status, and to discharge the patient from the recovery area according to accepted
guidelines.
Intent of 17.2.3
Physiological monitoring provides reliable information about the patient's status during the
administration of anaesthesia and the recovery period. Monitoring methods depend on the patient's
pre-anaesthetic status, anaesthetic choice, and complexity of the surgical or other procedure
performed during anaesthesia. In all cases, however, the monitoring process is continuous, and the
results are entered into the patient's record.
Monitoring during anaesthesia provides the basis for monitoring during the post-anaesthetic recovery
period. The ongoing, systematic collection and analysis of data on the patient's status in recovery may
support decisions about moving the patient to other settings and less intensive services. Only a
suitably qualified and experienced registered nurse or designated medical staff may carry out
monitoring in the recovery area. Recording of monitoring data provides the documentation to support
discharge decisions.
The anaesthetist or other qualified individual decides whether the patient can be discharged from the
recovery area to another level of care or from the organisation (as in the case of ambulatory
anaesthesia). Standardised criteria developed by medical staff are used to make discharge decisions.
The decision to discharge the patient from the recovery area, is entered into the patient's record. The
time of arrival in, and discharge from the recovery area are recorded. Signatures of those, who
handed over and those who received, the patient are recorded.
17.2.3 Criteria
17.2.3.1. The anaesthetist is responsible for supervising the recovery period.
17.2.3.2. Patients receive monitoring appropriate to their condition during the post- anaesthetic recovery
period.
17.2.3.3. The qualifications and experience of staff members who may monitor patients are documented.
17.2.3.4. Monitoring findings are entered into the patient’s record.
17.2.3.5. Established criteria are used to make discharge decisions from the recovery room.
17.2.3.6. The anaesthetist applies the criteria and discharges the patient.
17.2.3.7. The anaesthetist signs the patient out of the recovery area.
17.2.3.8. Recovery area arrival and discharge times are recorded.
17.2.3.9. Signatures of those handing over and of those receiving the patient are recorded.
17.3. Facilities, equipment, supplies and medication

17.3.1. Facilities for safe surgical and anaesthetic care are provided and maintained.
Intent of 17.3.1
The design of the operating theatre provides space for the reception, anaesthesia, surgery, recovery
and observation of patients.

There are areas for the disposal and collection of used equipment and waste, including contaminated
waste and sharps. Safe and adequate storage space for pharmaceutical and surgical supplies is
available, including separate lockable cupboards for schedule 7 substances and other scheduled
medicines and for inflammables.
Theatre staff are provided with office facilities or a day station, a restroom, washrooms, toilets, and
changing facilities, and a separate space for the staff's personal clothing and theatre clothing.
There are facilities for scrubbing-up procedures in each theatre, with hot and cold running water and
elbow-operated taps. There is an anaesthetist's chair, an operating table with Trendelenburg position
control, and at least one lateral padded straight arm support, and an infusion pole. Equipment for
patients awaiting surgery includes a baumanometer, vacuum point with ancillary fittings and oxygen
points with flowmeter and all ancillary fittings. Space and facilities are available for setting up surgical
trays and for autoclaving instruments.
17.3.1 Criteria
17.3.1.1. The design of the operating theatre complex provides space for the reception, anaesthesia, surgery,
recovery and observation of patients.
17.3.1.2. There is direct access to the operating theatres from the receiving, scrubbing-up and recovery areas.
17.3.1.3. The accommodation for patients awaiting surgery is suitably equipped.
17.3.1.4. There is safe and adequate storage space for pharmaceutical and surgical supplies.
17.3.1.5. Access to the theatre suites is controlled.
17.3.1.6. There is access to sterilisation and disinfection facilities.
17.3.1.7. There is a system for the environmental control of the temperature and humidity which ensures safe
limits for anaesthetised patients (temperature between 22 deg. and 25 deg. C, and relative humidity
between 40% and 70%).
17.3.1.8. Where resuscitation, intensive care, life support or critical monitoring equipment is used, which does
not have built-in battery backup units, there is an uninterruptible power supply (UPS), which complies
with relevant requirements and which is regularly serviced and tested.
17.3.1.9. There is either an UPS or a battery backup system for the theatre lamp, which is regularly tested, with
such tests being fully documented.
17.3.1.10. The theatre has a refrigerator for drugs and blood, the temperature of which is measured and
recorded daily.
17.3.2. Anaesthetic equipment, supplies and medications used comply with the
recommendations of anaesthetic professional organisations or alternate authoritative
sources.
Intent of 17.3.2
Anaesthetic risks are significantly reduced, when appropriate and well-functioning equipment is used
to administer anaesthesia and monitor the patient. Adequate supplies and medications are also
available for planned use and emergency situations. Each organisation understands the required or
recommended equipment, supplies and medications, necessary to provide anaesthetic services to its
patient population. Recommendations on equipment, supplies and medications can come from a
government agency, national or international anaesthetic professional organisations or other
authoritative sources. There is an equipment maintenance programme.
17.3.2 Criteria
17.3.2.1. The provision and use of anaesthetic mixture components complies with the guidelines for practice of
the professional society.
17.3.2.2. The provision and use of breathing circuits complies with the guidelines for practice of the
professional society.
17.3.2.3. The provision and use of ancillary equipment complies with the guidelines for practice of the

17.3.2.4. The provision and use of monitoring equipment complies with the guidelines for practice of the
17.3.2.5. Recommended medications are used.
17.3.2.6. A drug trolley is available for the exclusive use of the anaesthesiologist in each theatre.
17.3.2.7. A tracheotomy tray is available.
17.3.2.8. Theatre staff ensure that all equipment is included in the organisation’s equipment replacement and
maintenance programme.
17.3.3. Emergency and protective equipment are provided in the operating theatre.
Intent of 17.3.3
Theatre staff must prepare for any emergencies through the provision of emergency and protective
equipment.
17.3.3 Criteria
17.3.3.1. Emergency resuscitation equipment is available.
17.3.3.2. Emergency resuscitation equipment shows evidence of regular checking.
17.3.3.3. There is a mechanism for summoning assistance.
17.3.3.4. There is appropriate shielding and protective clothing in the presence of biohazards (including lasers)
or radiographic equipment.
17.3.3.5. Emergency and resuscitation equipment and supplies have clearly defined instructions for use.
17.3.3.6. Hazard or warning notices are displayed.
17.3.4. Recovery room facilities and equipment are available to provide safe and
effective care.
Intent of 17.3.4
The number of beds/trolley spaces in the recovery room provides sufficient space for at least one
patient from each operating theatre that it services, and is sufficient for peak loads. The provision, use
and maintenance of recovery room equipment comply with the guidelines for practice of the
17.3.4 Criteria
17.3.4.1. The recovery area forms part of the operating suite.
17.3.4.2. There are an adequate number of recovery beds for the patients from the operating theatre.
17.3.4.3. There is adequate lighting.
17.3.4.4. The provision, use and maintenance of recovery room equipment comply with the guidelines for
practice of the relevant professional society.

theatre and anaesthetic services.
Intent of 17.4.1

17.4.1 Criteria
17.4.1.1. There is a written quality improvement programme for the theatre and anaesthetic services, which is
17.4.1.4. Processes are selected in order of priority, for evaluation and improvement in the quality of treatment
and care.

17.5.1. The organisation is responsible for providing processes, which support
patient and family rights during care.
17.5.1 Criteria
17.5.1.1. There are processes, which support patient and family rights during care.
17.5.1.2. There are processes to ensure that care is respectful of the patient’s personal values and beliefs.
17.5.1.3. Measures are taken to protect the patient’s privacy, person and possessions.
17.5.1.4. The staff respect the rights of patients and families to treatment and to refuse treatment.
17.6. Prevention and control of iection

17.6.1 Criteria
17.6.1.3. Individuals, who collect specimens, are trained in the proper collection and handling of microbiological
specimens.
infection control.
17.6.1.5. The department provides education on infection control practices to staff, doctors, patients, and as
appropriate, the families and other caregivers.

include health and safety programmes, which comply with legislation.
17.7.1 Criteria
safety programme.
17.7.1.2. There is a programme for the inspection of theatre facilities and a plan to reduce fire risks for the
protection of patients and staff.
17.7.1.4. There is a procedure for the handling, storage and disposal of clinical wastes.
17.7.1.5. There is a plan, which is implemented, for the safeguarding and protection of buildings, staff and
visitors.

17.7.1.7. There are policies and procedures for the monitoring of data on incidents, injuries and other events,
which support planning and further risk reduction.


18.Nuclear Medicine
Overview of Nuclear Medicine

Organisations may provide nuclear medicine services as part of an integrated system of services, or
may have an arrangement with an outside source for the referral of patients.
The selection of an outside source is based on an acceptable record and compliance with laws and
regulations.
Where the organisation provides its own nuclear medicine services, these comply with applicable local
and national standards, laws and regulations.
Radiation safety programmes are complied with, and policies and procedures guide staff in the
application of safety measures.

Standards
18.1. Referral services

18.1.1. Where there is an arrangement with an outside service, this service meets
applicable local and national standards, laws and regulations.
Intent of 18.1.1
The organisation has a system for providing nuclear medicine services required by its patient
population, clinical services offered, and healthcare provider needs. These services may be provided
by agreement with another organisation. The organisation defines the time period for reporting nuclear
medicine results. Results are reported within a time frame based on patient needs, services offered,
and the clinical staff's needs. Emergency tests and after-hours and weekend testing needs are
included. The reports are submitted timeously, in accordance with arrangements.
When the organisation uses outside sources of nuclear medicine services, they receive and review, on
a regular basis, the quality control results of the outside source. Qualified individuals review the quality
control results.
Patients are informed, when the referring physician owns an outside source of radiology services.
18.1.1 Criteria
18.1.1.1. Adequate, convenient and regular nuclear medicine services are available to meet needs.
18.1.1.2. The selection of an outside source is based on an acceptable record and compliance with laws and
regulations.
18.1.1.3. Patients are informed about any relationships between the referring physician and outside sources of
nuclear medicine services.
18.1.1.4. The nuclear medicine services provided meet applicable local and national standards, laws and
regulations.
18.1.1.5. The organisation has established the expected report time for results within a time frame to meet
patient needs.
18.1.1.6. Reports are clearly labelled with the name of the patient, and the date and time of the procedures.
18.1.1.7. Quality control results from outside sources are regularly reviewed.
18.1.1.8. Qualified individuals review the quality control results.
18.2. Management of the service

18.2.1. Where the organisation provides on-site nuclear medicine services, the
service is organised and managed in accordance with laws, regulations and
standards.
Intent of 18.2.1
Where the organisation provides an on-site service, suitably qualified and experienced managers
ensure that the service is managed in accordance with applicable laws, regulations and standards.
18.2.1 Criteria
18.2.1.1. Nuclear medicine services are under the direction of one or more qualified individuals.
18.2.1.2. All professional staff are currently registered.
18.2.1.3. There are qualified nuclear radiographers to provide services in keeping with the scope of their
profession.
18.2.1.4. A qualified medical radiation physicist is available to fulfil the legal requirements of the regulations for
the safe use of ionising radiation.
18.2.1.5. The services of a qualified radiopharmacist or nuclear medicine radiographer are available for
radiopharmaceutical preparation.

18.2.1.6. Responsibilities include developing, implementing and maintaining policies and procedure
18.2.1.7. Responsibilities include administrative control.
18.2.1.8. Responsibilities include maintaining quality control programmes.
18.2.1.9. Responsibilities include monitoring and reviewing all nuclear medicine services.
18.2.1.10. These responsibilities are carried out.
18.3. Radiation safety

18.3.1. A radiation safety programme is in place, followed and documented.
Intent of 18.3.1
The organisation has an active radiation safety programme, appropriate to the risks and hazards
encountered. The programme addresses safety practices and prevention measures for nuclear
medicine staff, other staff and patients. The programme is co-ordinated with the organisation's safety
management programme.
The radiation safety programme includes:
• written polices and procedures, which support compliance with applicable standards, laws and
regulations;
• written polices and procedures for the handling and disposal of infectious and hazardous materials;
• the availability of safety protective devices appropriate to the practices and hazards encountered;
• the orientation of all nuclear medicine staff to safety procedures and practices; and
• in-service education for new procedures and newly acquired or recognised hazardous materials.
18.3.1 Criteria
18.3.1.1. A radiation safety programme is in place and is appropriate to the risks and hazards encountered.
18.3.1.2. The programme is co-ordinated with the organisation's safety management programme.
18.3.1.3. Personal dosimeters worn by staff comply with the ionising radiation regulations.
18.3.1.4. Appropriate radiation safety devices are available.
18.3.1.5. Written records of radioactive stocks, calculation and preparation, administration and disposal details
are kept.
18.3.1.6. A register is kept of sealed sources.
18.3.1.7. Contamination monitors are provided.
18.3.1.8. Area monitors are available where necessary.
18.3.2. There are written policies and procedures to guide staff in all aspects of the
provision of nuclear medicine services.
Intent of 18.3.2
Written policies and procedures are essential to guide staff in the nuclear medicine service in their
activities. The existence of written procedures does not preclude modification in the best interests of
the patient.
Nuclear medicine policies and procedures are related to the requirements or availability of other
services in the hospital environment.
18.3.2 Criteria
18.3.2.1. Written policies and procedures address compliance with applicable standards, laws and regulations.
18.3.2.2. The associated medical physicist is involved in the formulation of polices and radiation safety
procedures applicable to nuclear medicine.

18.3.2.3. Policies and procedures satisfy statutory requirements under the ionising radiation regulations.
18.3.2.4. A copy of the local rules relating to current ionising radiation regulations is available.
18.3.2.5. Policies and procedures relate to limiting the irradiation of patients to levels consistent with medical
requirements. The ALARA (as low as reasonably achievable) principle in the calculation, preparation
and administration of radioactive doses is applied.
18.3.2.6. There is a strict policy on the terms under which pregnant women may be subjected to a nuclear
medicine examination.
18.3.2.7. There is a procedure to ensure professional handling of a radiation emergency situation.
18.3.2.8. Policies and procedures relate to avoiding radioactive contamination and controlling spread should it
occur.
18.3.2.9. A written procedure is available for staff to follow in the event of contamination.
18.3.2.10. There are policies relating to monitoring the hands, clothing and body of every member of staff
leaving a controlled area.
18.3.2.11. Policies and procedures are developed for the reporting of adverse reactions to therapy.
18.3.2.12. Policies and procedures are developed for clinical trials, where applicable.
18.3.2.13. Written policies and procedures address the handling and disposal of infectious and hazardous
materials.
18.3.2.14. Nuclear medicine staff are oriented to safety procedures and practices.
18.3.2.15. Staff receive education for new procedures and newly acquired or recognised hazardous materials.
18.3.3. All diagnostic equipment is regularly inspected and maintained, and

appropriate records are kept of these activities.
Intent of 18.3.3
Nuclear medicine staff work with medical equipment management to ensure that all equipment and
facilities function at acceptable levels and in a manner that is safe for the operator(s). A nuclear
medicine equipment management programme provides for:
• selecting and acquiring equipment;
• identifying and taking an inventory of equipment;
• assessing equipment use through inspection, testing and maintenance;
• monitoring and acting on equipment hazard notices, recalls, reportable incidents, problems and
failures; and
• documenting the management programme.
Testing and maintenance are related to the use of the equipment and its documented history of
service.
18.3.3 Criteria
18.3.3.1. There is a nuclear medicine equipment management programme.
18.3.3.2. The programme includes selecting and acquiring equipment.
18.3.3.3. The programme includes taking an inventory of equipment.
18.3.3.4. The programme includes inspecting and testing equipment.
18.3.3.5. The programme includes the maintainance of equipment.
18.3.3.6. The programme includes monitoring and follow-up.
18.3.3.7. Radiation monitors are calibrated regularly.
18.3.3.8. Values are recorded in a log book.
18.3.3.9. The programme is followed.
18.3.3.10. There is adequate documentation of all testing, maintenance and calibration of equipment.
18.3.4. Facilities ensure the safe, efficient and effective functioning of the nuclear
medicine service.
Intent of 18.3.4

Nuclear medicine staff work with management to ensure that facilities provide for safety and that they
comply with current nuclear medicine laws and regulations.
18.3.4 Criteria
18.3.4.1. Facilities ensure that radiation to staff is kept as low as possible.
18.3.4.2. At every entrance to a room where radioactive material is handled a radiation warning sign is
displayed.
18.3.4.3. Requirements laid down by the Department of Health regarding a controlled area are complied with.
18.3.4.4. A copy of the most recent radiation safety inspection report is held by the nuclear physician
responsible for the department, or the medical physics department, or medical physicist.
18.3.4.5. There is a shower available in the event of contamination.
18.3.4.6. Separate toilets for staff and patients are available.
18.3.4.7. Signs warning of the dangers of radiation to pregnant and breast-feeding women are prominently
displayed.
18.3.5. Radio-pharmaceuticals intended for administration to patients are prepared in

a manner which satisfies both radiation safety and pharmaceutical quality
requirements.
Intent of 18.3.5
Sound quality control systems are essential to providing excellent nuclear medicine services. Quality
control procedures include:
• validation of the procedures used;
• daily surveillance of results by a nuclear medicine physician;
• rapid corrective action, when a deficiency is identified; and
• documentation of results and corrective actions.
18.3.5 Criteria
18.3.5.1. Appropriate aseptic precautions are taken.
18.3.5.2. Regular and frequent gamma camera quality control procedures (e.g. flood uniformities, centre-of-
rotation) are attended to or supervised by the medical physicist.
18.3.5.3. The radio-pharmacy is designed to ensure that the history of each radio-pharmaceutical dose can be
traced.
18.3.5.4. Radio-pharmaceuticals are only dispensed on written request.
18.3.5.5. All details of each Tc-99m generator are recorded, including full details of each elution.
18.3.5.6. Facilities are available for the quality control of all kits reconstituted on the premises.
18.3.5.7. There are separate facilities for the radio labelling of blood products.
18.3.5.8. Blood products are labelled in a workstation with filtered air (at least a vertical laminar flow unit of
biohazard type) to protect the product and designed to protect the operator against contamination.
18.3.5.9. All containers with radioactivity are labelled according to specifications, stating that the contents are
radioactive and indicating the activity and the date.
18.3.6. The management of organ disease using open radionuclides is practised

taking into account the safety and well-being of patients and staff as a consequence
of the high radiation levels.
Intent of 18.3.6
Where open radio-nuclides are used, all staff and patients in the organisation are protected from
exposure to radiation by following established guidelines, which are formulated by experts in the field.
Supervision ensures that the guidelines are adhered to.
18.3.6 Criteria

18.3.6.1. Where radioactive material administered to the patient exceeds a level of 370 MBq (10mCi), it is
administered by the nuclear physician or radiation oncologist only.
18.3.6.2. Where radioactive material administered to the patient exceeds a level of 370 MBq (10mCi), there is
an en-suite ward approved by the medical physicist for the isolation of the patient.
18.3.6.3. In the event that the approved ward is not available, any alternative ward for the isolation of the
therapy patients is also approved by the medical physicist.
18.3.6.4. A radiation survey of the ward used for the isolation of the patient and adjacent areas is conducted
according to the requirements of the physicist immediately after the administration of the radioactive
material.
18.3.6.5. The isolated patient is monitored regularly during the isolation period.
18.3.6.6. On discharge of the patient who has been isolated, the ward, the bedding and the bathroom are
monitored according to the requirements of the physicist.
18.3.6.7. Orally administered radio-iodine is always in capsule form.
18.3.6.8. Radio-iodine by injection (e.g. MIGB) is administered only by the nuclear physician or radiation
oncologist.
18.3.6.9. A fume hood is used if liquid radio-iodine is being prepared, and the staff preparing the radio-iodine
are adequately protected.
18.3.6.10. Administration of all radionuclides for therapy purposes is done in consultation with the physicist and
according to statutory radiation safety norms.
18.4. Administration of tests

18.4.1. Individuals with adequate training, skills, orientation and experience
administer tests and interpret the results.
Intent of 18.4.1
The organisation identifies which nuclear staff members may assess patients and who may interpret
and report on results. Staff have appropriate and adequate training, experience and skills and are
oriented to their work. Staff are given work assignments consistent with their training and experience.
In addition, there are a sufficient number of staff to perform procedures promptly and provide the
necessary staffing during all hours of operation and for emergencies.
18.4.1 Criteria
18.4.1.1. Examinations are performed only upon a formal request from a medical practitioner.
18.4.1.2. Nuclear medicine procedure requests contain relevant clinical information.
18.4.1.3. If relevant radionuclides are available, all examinations are performed as soon as possible. Urgent
scans are performed and reported on the same day.
18.4.1.4. Those individuals who perform testing and those who direct or supervise testing are identified.
18.4.1.5. Tests are interpreted by appropriately trained and experienced staff.
18.4.1.6. A nuclear medicine physician or registrar under supervision of a nuclear medicine physician, or a
radiologist reports on the results of nuclear medicine procedures.
18.4.1.7. An effective mechanism exists whereby emergency nuclear medicine procedure results are brought
to the attention of the doctor who requested the examination.
18.4.1.8. Nuclear medicine procedure results are handled in a professional and confidential manner.
18.4.1.9. Reports are appropriately filed/ distributed.
18.4.1.10. Mechanisms exist whereby the results of procedures can be retrieved when necessary.

nuclear medicine service.
Intent of 18.5.1
It is the responsibility of the management of the organisation, to ensure that standards are set

ensure that standards are set for that particular department. This requires co-ordination with the
18.5.1 Criteria
18.5.1.1. There is a written quality improvement programme for the nuclear medicine service that is developed
and agreed upon by the personnel of the service.
and care.
18.5.1.5. The quality improvement cycle includes the monitoring and evaluation of the standards set and the


19.Laboratory service
Overview of Laboratory service

Laboratory investigations and rapid reporting systems are essential for patient assessment and the
implementation of treatment plans.
The hospital may have its own laboratory service, or it may have an arrangement with an outside
laboratory service, for accepting laboratory specimens for analysis. In either case, the service must
meet applicable laws and regulations.
The selection of an outside source is based on an acceptable record and compliance with laws and
regulations.
Laboratory services must be available at those times needed by the organisation, including emergency
and after-hour services.

Standards

19.1.1. Laboratory services are available to meet the needs of patients, in
compliance with laws, regulations and standards.
Intent of 19.1.1
The organisation provides the laboratory services required by its patient population, clinical services
offered, and healthcare providers' needs.
Laboratory results are validated to ensure the correct patient and physician.
Validations include the name of the validating office.
Results are reported within a time frame based on patient needs, services offered, and the clinical
staff's needs. Emergency tests and after-hours and weekend testing needs are included. Appropriate
specimen containers are available in the organisation, with instructions for their correct usage.
19.1.1 Criteria
19.1.1.1. Adequate, convenient and regular laboratory services are available to meet the organisation’s needs.
19.1.1.2. The laboratory services are organised and provided in a manner that meets applicable local and
national standards, laws and regulations.
19.1.1.3. Emergency laboratory services are available, including after-hours services.
19.1.1.4. The organisation has established the expected report time for results.
19.1.1.5. Laboratory results are reported within a time frame to meet patient needs.
19.1.1.6. Laboratory results are validated and include unique patient identity, date of testing/reporting, name
and location of requesting physician.
19.1.1.7. The validating officer is identified and recorded.
19.1.2. A qualified individual is responsible for managing the laboratory service.

Intent of 19.1.2
The laboratory service is under the direction of an individual, who is qualified by virtue of documented
training, expertise and experience, in accordance with applicable laws and regulations.. This individual
assumes professional responsibility for the laboratory facility and for the services provided. When this
individual provides clinical consultations or medical opinions, he or she is a physician, preferably a
pathologist. Speciality and subspecialty laboratory services are under the direction of appropriately
qualified individuals. Responsibilities of the laboratory director include the:
• ordering of tests;
• collecting and identifying of specimens;
• transporting, storing and preserving of specimens; and
• receiving, logging in and tracking of specimens.
These procedures are also observed for specimens sent to outside sources for testing.
19.1.2 Criteria
19.1.2.1. The laboratory is under the direction of a qualified individual.
19.1.2.2. The responsibilities of this person include maintaining quality control programmes.
19.1.2.3. The responsibilities of this person include administrative supervision.
19.1.2.4. The responsibilities of this person include the monitoring and reviewing of all laboratory services.

19.1.3. Individuals with adequate training, skills, orientation and experience

administer tests and interpret the results.
Intent of 19.1.3
The organisation identifies which laboratory staff members may perform testing and who may direct or
supervise testing. Supervisory staff and technical staff have appropriate and adequate training,
experience and skills, and are oriented to their work. Technical staff are given work assignments
consistent with their training and experience. In addition, there are a sufficient number of staff to
perform tests promptly and to provide the necessary laboratory staffing during all hours of operation
and for emergencies.
The organisation is able to identify and contact experts in specialised diagnostic areas, such as
parasitology or virology, when needed.
19.1.3 Criteria
19.1.3.1. Those individuals, who may perform testing and those who may direct or supervise testing, are
identified.
19.1.3.2. Appropriately trained and experienced staff administer tests.
19.1.3.3. Appropriately trained and experienced staff interpret tests.
19.1.3.4. There is an adequate number of staff to meet patient needs.
19.1.3.5. Supervisory staff have appropriate training and experience.
19.1.3.6. Technical staff have appropriate training and experience.
19.1.3.7. A roster of experts for specialised diagnostic areas is maintained.
19.1.3.8. Experts in specialised diagnostic areas are contacted, when needed.
19.1.3.9. There is a record of each test done, by whom, the result thereof, and a monthly summary.
19.1.4. All laboratory equipment is regularly inspected, maintained, and calibrated,

and appropriate records are maintained for those activities.
Intent of 19.1.4
Laboratory staff work to ensure that all equipment functions at acceptable levels and in a manner that
is safe to the operator(s). A laboratory equipment management programme provides for:
• selecting, acquiring and replacing equipment;
• identifying and taking an inventory of equipment;
• assessing equipment use through inspection, testing, calibration and maintenance;
• the monitoring of and acting on equipment hazard notices, recalls, reportable incidents, problems
and failures.
• documenting the management programme.
Testing, maintenance and calibration frequency are related to the laboratory's use of equipment and its
documented history of service.
A named person is responsible for monitoring the temperature of the specimen fridge, which must be
maintained between 2 and 6 degrees centigrade, and other fridges in the laboratory.
19.1.4 Criteria
19.1.4.1. There is a laboratory equipment management programme.
19.1.4.2. The programme includes selecting, acquiring and replacing of equipment.
19.1.4.3. The programme includes taking an inventory of the equipment.
19.1.4.4. The programme includes inspecting and testing the equipment.
19.1.4.5. The programme includes calibrating and maintaining the equipment.

19.1.4.6. The programme includes monitoring and follow-up.

19.1.4.7. The programme is followed.
19.1.4.8. There is adequate documentation of all testing, maintenance and calibration of equipment.
19.1.4.9. A named person is responsible for the specimen and reagent fridges.
19.1.5. Essential and other supplies are regularly available.

Intent of 19.1.5
The organisation has identified those reagents and supplies, necessary to regularly provide laboratory
services to its patients. A process to order or secure those essential reagents and other supplies is
effective. All reagents are stored and dispensed according to defined procedures. The periodic
evaluation of all reagents ensures accuracy and precision of results. Written guidelines ensure the
complete and accurate labeling of reagents and solutions.
19.1.5 Criteria
19.1.5.1. Essential reagents and supplies are identified.
19.1.5.2. Essential reagents and supplies are available.
19.1.5.3. All reagents are stored and dispensed according to guidelines.
19.1.5.4. All reagents are periodically evaluated for accuracy and results.
19.1.5.5. All reagents and solutions are completely and accurately labelled.
19.1.6. Laboratory facilities are available for specific HIV/AIDS related tests in
accordance with national guidelines.
19.1.6 Criteria
19.1.6.1. Laboratory facilities include basic laboratory equipment according to national guidelines.
19.1.6.2. Basic laboratory equipment for HIV management includes a refrigerator maintained consistently
between 2 and 8 degrees C.
19.1.6.3. Basic laboratory equipment for HIV management includes a centrifuge which effectively spins down
blood samples to obtain adequate specimens for the measurement of plasma viral loads.
19.1.6.4. Basic laboratory equipment for HIV management includes the capacity to freeze samples to –20
degrees C. at central reference laboratories.
19.1.6.5. Basic laboratory equipment for HIV management includes a back-up generator for emergency
electricity supply.
19.1.6.6. Laboratory tests are utilised for HIV-positive patients according to local, national guidelines.
19.1.6.7. Accessible laboratory tests include basic haematology (full blood count and differential count) and
microscopy.
19.1.6.8. Accessible laboratory tests include basic immunological assessments, including total lymphocyte and
CD4 counts.
19.1.6.9. Accessible laboratory tests include, for those patients utilising antiretroviral agents, HIV viral load
assessments.
19.1.6.10. Accessible laboratory tests include, for those patients utilising antiretroviral agents includes resistance
testing.
19.1.6.11. Laboratory tests include basic chemistry and liver function testing facilities.
19.1.6.12. Laboratory tests include facilities for fasting lipograms.
19.1.6.13. Laboratory tests include fasting glucose assessments.
19.1.6.14. Laboratory tests include serum lactate.
19.1.6.15. Laboratory tests include DBS/PCR for PMTCT follow-up.
19.1.6.16. Laboratory tests include PAP smears.
19.2. Management of specimensand results

19.2.1. Procedures for collecting, identifying and safely transporting specimens are
followed.

Intent of 19.2.1
Procedures are developed and implemented for the:
• ordering of tests;
• collecting and identifying of specimens;
• transporting, storing and preserving of specimens; and
• receiving, logging in and tracking of specimens.
The procedures are observed for specimens sent to outside sources of testing, as well as for on-site
laboratories.
Records are kept of when results have been telephoned, at what time and to whom.
19.2.1 Criteria
19.2.1.1. Request forms and specimen labels include unique patient identification and adequate supporting
information.
19.2.1.2. There is a collection and delivery service, for specimens from the organisation, every weekday.
19.2.1.3. Specimens are given a laboratory specimen accession number.
19.2.1.4. Procedures guide the ordering of tests.
19.2.1.5. Procedures guide the collection and identification of specimens.
19.2.1.6. Procedures guide the transport, storage and preservation of specimens.
19.2.1.7. Emergency results may be obtained by telephone.
19.2.2. Established norms and ranges are used to interpret and report laboratory
results.
Intent of 19.2.2
The laboratory establishes reference intervals or "normal" ranges for each test performed. The range
is included in the clinical record, either as part of the report or by including a current listing of such
values, approved by the laboratory director. Ranges are furnished, when an outside source performs
the test. The reference ranges are appropriate to the organisation's patient population and are
reviewed and updated, when methods change.
19.2.2 Criteria
19.2.2.1. The laboratory has established reference ranges for each test performed.
19.2.2.2. The range is included in the clinical record at the time test results are reported.
19.2.2.3. Ranges are furnished when tests are performed by outside sources.
19.2.2.4. Ranges are appropriate to the organisation’s patients.
19.2.2.5. Ranges are reviewed and updated, as needed.
19.3. Quality management

19.3.1. A formalised quality control programme and a proactive quality improvement
approach are maintained in the laboratory service.
Intent of 19.3.1
It is the responsibility of the management of the organisation, to ensure that standards are set
throughout the organisation. Within each department or service, it is the responsibility of the
managers, to ensure that standards are set for the particular department. This requires co-ordination
with the organisation's steering committee. Departmental managers use available data and
information to identify priority areas for quality monitoring and improvement.

19.3.1 Criteria
19.3.1.1. There is a written quality improvement programme for the laboratory service, which has been
19.3.1.3. Indicators of performance are identified, to evaluate the quality of tests provided to patients and must
include the validation of test methods, the daily surveillance of test results and a system of proficiency
testing.
19.3.1.4. Processes are selected in order of priority, for evaluation of and improvement in the quality of service.
19.3.1.5. The quality improvement cycle includes the monitoring and evaluation of the standards set.
19.3.1.6. The quality improvement cycle includes the remedial actions implemented, which include the rapid
correction of deficiencies and documentation of results and corrective actions.

19.4.1. There is a comprehensive infection prevention and control programme, to
safeguard employee health.
19.4.1 Criteria
19.4.1.1. There is a programme, which is implemented, to reduce the risks of nosocomial infections in
healthcare workers.
19.4.1.2. The service identifies the procedures and processes associated with the risk of infection, and
19.4.1.3. Individuals, who handle specimens, are trained in the proper handling of dangerous specimens.
19.4.1.4. The service participates in the overall programme for quality management and improvement of
infection control.
19.4.1.5. The service provides education on infection control practices to the staff.

19.5.1. The organisation implements risk management programmes, including health
and safety programmes, which comply with legislation relating to health and safety.
19.5.1 Criteria
19.5.1.1. The health and safety representative for the service supervises implementation of the health and
safety programme.
19.5.1.2. The laboratory safety programme is appropriate for the risks and hazards encountered.
19.5.1.3. All staff are trained regarding their role in providing a safe and secure laboratory care facility, and
receive a copy of the safety regulations for which they sign.
19.5.1.4. A list of safety regulations, including hazards is displayed.
19.5.1.5. Written policies and procedures address the handling, storage and disposal of laboratory waste
(infectious, hazardous, and clinical).
19.5.1.6. Written procedures are available on chemicals, poisons and radio-active isotopes.
19.5.1.7. Appropriate safety devices are available.
19.5.1.8. Written policies and procedures are available on the monitoring of data on incidents, injuries and
other events, which support planning and further risk reduction.
19.5.1.9. There is a programme for the inspection of laboratory buildings and a plan to reduce fire risks for the
protection of staff.
19.5.1.10. There is a plan to protect buildings and staff.

20.Radiology service
Overview of Radiology service

The organisation is responsible for ensuring that the radiology service meets the needs of its patient
population, the clinical services offered, and the healthcare providers.
These needs may be met by a service within the organisation, or may be outsourced. In either case,
the radiology service must comply with all applicable local and national standards, laws and
regulations.
The organisational leaders ensure that where a radiology service is provided by the facility, there are
radiation safety programmes in place, and that individuals with adequate training, skills, orientation and
experience are available to undertake X-ray procedures and interpret the results.
The radiology service allows for immediate decision-making by practitioners, through the provision of
emergency services and the provision of emergency reports, as necessary.

Standards

20.1.1. A radiology service is provided by the organisation, or is readily available
through arrangements with outside sources, to meet the needs of its patient
population.
Intent of 20.1.1
The organisation has a system for providing the radiology service, required by its patient population,
the clinical services offered, and healthcare providers.
The radiology service, including that required for emergencies, may be provided within the
organisation, by agreement with another organisation, or both. The radiology service is available after
normal hours for emergencies.
Outside sources are convenient for the patient to access, and reports are received in a timely manner,
which supports continuity of care. They are selected by the organisation on the recommendation of
the director or another individual responsible for the radiology service. Radiology tests performed by
outside contractors are reported according to organisation policy or contract requirements. Outside
sources of radiology meet applicable laws and regulations and have an acceptable record of accurate,
timely service. Patients are informed when the referring physician owns the outside source of
radiology.
20.1.1 Criteria
20.1.1.1. An adequate, convenient and regular radiology service is available to meet needs.
20.1.1.2. An emergency radiology services is available after normal hours.
20.1.1.3. The selection of an outside source is based on an acceptable record and compliance with applicable
laws and regulations.
20.1.1.4. Patients are informed about any relationships between the referring physician and an outside source
of radiology service.
20.1.2. A qualified individual is responsible for managing the radiology service.

Intent of 20.1.2
The radiology service is under the direction of an individual, who is qualified by virtue of documented
training, expertise and experience, in accordance with applicable laws and regulations. This individual
assumes professional responsibility for the radiology service. When this individual provides clinical
consultation or a medical opinion, he or she is a physician, preferably a radiologist.
The radiology director's responsibilities include:
• developing, implementing and maintaining policies and procedures;
• administrative control;
• maintaining any necessary quality control programmes;
• recommending outside sources of radiology services; and
• monitoring and reviewing all radiology services.
20.1.2 Criteria
20.1.2.1. A radiologist or radiographer, who is qualified by education, training and experience, manages the
radiology service.

20.1.2.2. The responsibilities of this person include developing, implementing and maintaining relevant policies
and procedures
20.1.2.3. The responsibilities of this person include administrative control
20.1.2.4. The responsibilities of this person include maintaining quality control programmes
20.1.2.5. The responsibilities of this person include recommending outside sources of radiology services
20.1.2.6. The responsibilities of this person include monitoring and reviewing all radiology services.
20.1.3. Individuals with adequate training, skills and experience perform X-ray
procedures and interpret the results.
Intent of 20.1.3
The organisation identifies those staff, who may perform procedures and those, who may interpret X-
ray films and report the findings.
These staff members have appropriate and adequate training, experience and skills, and are oriented
to their work. Radiographers are given assignments consistent with their training and experience.
There are sufficient staff to provide necessary staffing during all hours of operation and for
emergencies.
The organisation is able to identify and contact experts in specialised diagnostic areas such as
radiation physics, radiation oncology, or nuclear medicine, when the need for such services arises.
The organisation maintains a roster of such experts.
20.1.3 Criteria
20.1.3.1. Those individuals, who may perform X-ray procedures and those, who may interpret and report the
results are identified.
20.1.3.2. A mechanism exists, which ensures that procedures are performed only by radiographers,
radiologists, or specially trained doctors and other persons, authorised to do so by a radiation
protection advisor.
20.1.3.3. X-rays are done only upon a signed request from a qualified medical practitioner.
20.1.3.4. X-rays are interpreted and reported on by appropriately trained and experienced staff.
20.1.3.5. There is an adequate number of staff to meet patient needs.
20.1.3.6. Experts in specialised diagnostic areas are contacted, when needed.
20.1.3.7. A roster of experts for specialised diagnostic areas is maintained.
20.1.4. The radiology service meets applicable local and national standards, laws
and regulations.
Intent of 20.1.4
The organisation ensures that staff are knowledgeable about the relevant legal requirements relating
to radiology. This is ensured, by having available copies of the most recent radiation safety report and
local rules, relating to current Ionising Radiation regulations, and other applicable documents, which
provide guidance relating to legality.
The organisation satisfies the statutory requirements under the Ionising Radiation regulations,
according to the most recent radiation safety report.
There are organisational arrangements, which allow for advice on radiation protection and how to deal
with a suspected case of overexposure.
20.1.4 Criteria
20.1.4.1. Written policies and procedures address compliance with applicable standards, laws and regulations.

20.1.4.2. A copy of the local rules relating to current Ionising Radiation regulations is held.
20.1.4.3. A copy of the most recent radiation safety report is held.
20.1.4.4. The organisation satisfies the statutory requirements under the Ionising Radiation regulations.
20.1.4.5. A radiation protection supervisor is identified and available to assist a radiation protection adviser in
complying with the Ionising Radiation regulations.
20.1.4.6. A patient index is held in the radiology department.
20.2. Radiation safety programmes

20.2.1. X-ray film and other supplies are regularly available.
Intent of 20.2.1
The organisation has identified the quantities of film, reagents and supplies necessary to provide a
radiology service to its patients. A process to order or secure essential film, reagents and other
supplies is effective. All supplies are stored and dispensed, according to defined procedures. The
periodic evaluation of reagents ensures accuracy and precision of results. Written guidelines ensure
the complete and accurate labelling of film, reagents and solutions.
20.2.1 Criteria
20.2.1.1. Essential quantities of film, reagents and supplies are identified.
20.2.1.2. Essential quantities of film, reagents and supplies are available.
20.2.1.3. All film and reagents are stored and disposed of, according to guidelines.
20.2.1.4. All reagents and solutions are completely and accurately labelled.
20.3. Reporting and recording

20.3.1. Reporting and recording policies and procedures within the radiology service
ensure safety and legality.
Intent of 20.3.1
X-ray request forms and the ensuing reports must identify the correct patient and the correct site of X-
ray. The organisation defines the time period for reporting diagnostic radiology test results. Results
are reported within a time frame based on patients' needs, services offered, and clinical staff's needs.
Mechanisms are in place to ensure that X-ray results are reported on immediately in an emergency.
The X-ray films are the property of the patient, and may be taken away by the patient. Where this is
done, he/she must be told to bring the films along at future visits. Where the organisation stores films,
these are kept for a minimum of three years or longer as defined by organisational policy.
20.3.1 Criteria
20.3.1.1. X-ray request forms contain the patient’s name, examination requested, relevant previous
examinations and clinical information to explain the request.
20.3.1.2. The X-ray request form includes information regarding previous investigations.
20.3.1.3. The organisation has established the expected report time for results.
20.3.1.4. Radiology results are reported on within a time frame to meet patient needs.
20.3.1.5. There is a method of checking the X-ray reports against the clinical records.
20.3.1.6. X-ray reports contain a clear conclusion (including recommendations for future treatment if
appropriate).
20.3.1.7. A copy of the report is filed in the patient’s record.
20.3.1.8. Films are available at each visit of the patient.
20.3.1.9. Policy defines the length and method of storage of X-ray films.


radiology service.
Intent of 20.4.1
throughout the organisation. Within each department or service, it is the responsibility of the managers
to ensure that standards are set for the particular department. This requires co-ordination with the
20.4.1 Criteria
20.4.1.1. There is a written quality improvement programme for the radiology service, which has been
20.4.1.4. Processes are selected in order of priority for evaluation of and improvement in the quality of
treatment and care.
20.4.1.5. The quality improvement cycle includes the monitoring and evaluation of the standards set, and any

20.5.1 Criteria
20.5.1.2. There are processes to ensure, that care is respectful of the patient’s personal values and beliefs.

20.6.1 Criteria
infection control.
20.6.1.4. The department provides education on infection control practices to the staff.


20.7.1 Criteria
20.7.1.1. The health and safety representative for the service supervises the implementation of the health and
safety programme.
20.7.1.2. The programme is co-ordinated with the organisation's safety management programme.
20.7.1.3. Appropriate radiation safety devices are available.
20.7.1.4. Dosimeter badges are worn and handled according to Ionising Radiation Regulations.
20.7.1.5. Written policies and procedures address the handling, storage and disposal of infectious and
hazardous materials including clinical waste.
20.7.1.7. There is a programme for the inspection of patient care buildings and a plan to reduce fire risks, for
visitors.
20.7.1.9. There is a plan to respond to likely community emergencies, epidemics, and other disasters.
20.7.1.10. All staff are orientated and trained, regarding their role in providing a safe and secure patient care
facility.

21.Pharmaceutical service
Overview of Pharmaceutical service

A healthcare organisation must ensure that appropriate medications are available and dispensed to
meet the needs of the patient population. Appropriately qualified and experienced pharmacy staff
ensure that the pharmaceutical service and medication use comply with applicable laws and
regulations.
The prescribing, ordering and administration of medications are guided by policies and procedures,
which are known to and implemented by the organisation's staff.
The organisation identifies qualified individuals who are permitted to prescribe medications and those
permitted to administer medications. Systems are available to ensure, that those who are not
registered pharmacists, are supervised and practise in accordance with current local laws.
Pharmacists ensure collaboration with all other relevant departments, where medications are used and
stored.
Systems ensure that medications are safely stored and maintained.

Standards

21.1.1. Medication use is organised throughout the organisation, to meet the needs
of patients.
Intent of 21.1.1
As an important resource in patient care, medication use must be organised effectively and efficiently
throughout a healthcare organisation. Medication management is not only the responsibility of the
pharmaceutical service but also of the managers and clinical care providers. How this responsibility is
shared, depends on the organisation's structure and staffing. In those facilities, where there is no
pharmacy, medications may be managed in each clinical unit. In facilities, where there is a large
central pharmacy, the pharmacy may organise and control medications throughout the organisation.
Applicable laws and regulations are incorporated into the organisational structure and the operations of
the medication management system used in the organisation.
A registered pharmacist, who is qualified by education, training and experience, directly supervises the
activities of the pharmacy or pharmaceutical service.
Documentation, which guides the management of the service, is available and consulted, e.g.:current
Acts and regulations, relating to medication control.
21.1.1 Criteria
21.1.1.1. A registered pharmacist has clearly defined responsibilities and accountability for all aspects of the
pharmaceutical service.
21.1.1.2. There is a designated deputy, to act in the absence of the manager.
21.1.1.3. The responsibilities of the pharmacy manager include ensuring compliance with laws and regulations,
relating to the service.
21.1.1.4. The responsibilities of the pharmacy manager include ensuring compliance with pharmacy practice
and current pharmaceutical and other health professional guidelines, e.g. medical and nursing.
21.1.1.5. Designated staff members are qualified and/or experienced in ARV procurement, storage, and
dispensing, according to provincial and national guidelines.
21.1.1.6. The pharmaceutical service is co-ordinated with other related services in the facility and in the district.
21.1.1.7. Account is taken of current professional guidelines.
21.1.2. The pharmaceutical service is co-ordinated with other, related services in the
organisation.
Intent of 21.1.2
The pharmaceutical service works with all other departments in the organisation to ensure safe
medication usage and control, and to limit adverse drug reactions.
This communication is provided through committee meetings, such as Drugs and Therapeutics
Committee. Minutes of these meetings are circulated to all relevant departments.
Pharmaceutical staff work with other professional staff to identify their needs for in-service training and
provide such training as part of the organisation's in-service training programme.
Pharmacists visit wards and departments on a prescribed basis, to check prescriptions, administration
records, and storage and control of medicines.
21.1.2 Criteria
21.1.2.1. Collaboration exists between the pharmacy staff and other relevant staff in the organisation to ensure
safe prescribing, ordering, storage and dispensing of medications.

21.1.2.2. Communication exists between departments, in the form of appropriate committee meetings.
21.1.2.3. The pharmacy provides objective, consistent and reliable drug information to all health professionals.
21.2. Access to appropriate medication

21.2.1. An appropriate selection of medications for prescribing or ordering is stocked
or readily available.
Intent of 21.2.1
Every organisation must decide which medications to make available for prescribing and ordering by
the care providers. This decision is based on the organisation's mission, patient needs, and the types
of services provided. The organisation develops a list of all the medications it stocks or that are readily
available from outside sources. In some cases, laws or regulations may determine the medications on
the list or the source of those medications. Medication selection is a collaborative process, which
considers patient need and safety as well as economics. The organisation has a method, such as a
committee, to maintain and monitor this medication list and to monitor the use of medication within the
organisation.
Management of medication use in an organisation requires an understanding of the sources and uses
of medications, which are not prescribed or ordered within the organisation.
On occasion, medications not readily available to the organisation are needed. There are also
occasions where medications are needed at times when pharmacies are closed. Each organisation
needs to plan for these occurrences and to educate staff on the procedures to follow should they
occur. When patient emergencies occur, quick access to appropriate emergency medications is
critical. Each organisation plans the location of emergency medications, and the medications to be
supplied in these locations. To ensure access to emergency medications when needed, the
organisation establishes a procedure or process to prevent theft or loss of the medications, and to
ensure that medications are replaced when used, or when damaged or out of date.
Each organisation also needs to determine its role in providing medications to patients at discharge.
Those who prescribe or order medication know what medications, if any, are available and how to
obtain them.
21.2.1 Criteria
21.2.1.1. Medications, available for prescribing and ordering, are appropriate for the organisation’s mission,
patient needs and services provided.
21.2.1.2. There is a list of medications, stocked in the organisation, or readily available from outside sources.
21.2.1.3. A collaborative process was used to develop the list (unless determined by regulation or an agency
outside the organisation).
21.2.1.4. There is a method for control of the medication list.
21.2.1.5. There is a method for control of medication use within the organisation.
21.2.1.6. There is a process to obtain required medications not stocked, or normally available to the
organisation.
21.2.1.7. There is a process to obtain required medications, when the pharmacy is closed.
21.2.1.8. Emergency medications are available in the organisation within a time frame to meet emergency
needs.
21.2.1.9. Emergency medications are monitored and replaced in a timely manner, after use or when expired or
damaged.
21.2.1.10. Staff are knowledgeable about the processes for obtaining medications.
21.3. Policies and procedures

21.3.1. There is a collaborative effort to develop and monitor policies and procedures
for the pharmaceutical service.
Intent of 21.3.1
Safe pharmaceutical practices are guided by organisational policies and procedures. Medical,
nursing, pharmacy and administrative staff participate in a collaborative process to develop and
monitor the policies and procedures.
The availability and use of medication samples are controlled by the organisation.
Parenteral and enteral tube nutrition therapy is a component of medical treatment and must be
effectively managed, to reduce risk to the patient. A portion of that risk comes from the improper
storage, preparation, handling and distribution of parenteral and enteral products. To reduce such
risks, the organisation develops guiding policies and procedures.
The organisation ensures, that radioactive, investigational, cytostatic and other sterile admixtures, and
other medications, are safe and used appropriately. The storage, handling, distribution and dispensing
are governed by policies and procedures.
The organisation has a process for identifying, retrieving or returning or destroying medications,
recalled by the manufacturer or supplier. There is a policy or procedure, which addresses any use of,
or the destruction of, medications known to be expired or outdated.
21.3.1 Criteria
organisation.
21.3.1.2. Policies and procedures guide documentation requirements.
21.3.1.3. Policies and procedures guide the use of verbal medication orders.
21.3.1.4. Policies and procedures guide the availability and use of medication samples.
21.3.1.5. Policies and procedures guide the documentation and management of any medications, brought into
the organisation for or by the patient.
21.3.1.6. Policies and procedures guide the dispensing of medications at the time of the patient’s discharge.
21.3.1.7. Policies and procedures guide the preparation, handling, storage and distribution of parenteral
nutrition products.
21.3.1.8. Policies and procedures guide the preparation, handling, storage and distribution of enteral nutrition
products.
21.3.1.9. Policies and procedures guide the storage, handling, distribution and dispensing of hazardous
medications.
21.3.1.10. Policies and procedures guide the storage, handling, distribution and dispensing of investigational
medications.
21.3.1.11. Policies and procedures guide the management of medications used in clinical trials.
21.3.1.12. Policies and procedures guide security of staff, equipment and stock.
21.3.1.13. Policies and procedures guide dispensing outside contracted hours.
21.3.1.14. Policies and procedures guide the management of records and statistics.
21.3.1.15. Policies and procedures are implemented.
21.3.2. Policies and procedures address the procurement, quantities, storage and
sustainable supply of Anti-retroviral medicines (ARVs) as required by the facility.
21.3.2 Criteria
21.3.2.1. Stock control system are managed in the pharmacy and other related departments.
21.3.2.2. Stock control is monitored at protocol-defined intervals.
21.3.2.3. ARV medicines are procured according to national guidelines regarding specific agents and approved
suppliers.
21.3.2.4. ARV medicines are transported to the facility according to manufacturers’ guidelines, with specific
emphasis on maintenance of cold chain requirements.

21.3.2.5. The range and quantities of ARV agents maintained at the facility are in keeping with provincial and
national guidelines.
21.3.2.6. Policies and procedures guide stock maintenance, ordering and disposal of expired ARV stock.
21.3.2.7. ARVs are dispensed on the written instructions of a designated healthcare worker qualified and / or
experienced in their use (according to provincial and national guidelines).
21.3.2.8. ARVs are dispensed in conjunction with other medications only after thorough checking for drug
interactions by dispensing staff.
21.3.2.9. There is a uniform medication dispensing and distribution system in the facility and the district.
21.4. Prescriptions and orders

21.4.1. Dispensing of medications adheres to laws, regulations and professional
standards of practice.
Intent of 21.4.1
A registered pharmacist reviews each prescription or order for medication. When questions arise, the
individual who prescribed or ordered the medication is contacted.
The dispenser signs the prescription. When pharmacist assistants or interns dispense, they are
supervised, and their signatures, as dispensers, are countersigned by a registered pharmacist.
The organisation dispenses medications in the most ready-to-administer form possible, to minimise
opportunities for error during distribution and administration. The central pharmacy and other
medication distribution points throughout the organisation use the same system. The system supports
accurate dispensing of medications in a timely manner.
21.4.1 Criteria
21.4.1.1. Pharmacy staff act in accordance with legislation and current pharmaceutical, medical and nursing
guidelines.
21.4.1.2. There is a uniform medication dispensing and distribution system in the organisation.
21.4.1.3. The system supports accurate and timely dispensing.
21.4.1.4. Each prescription or order is reviewed by the pharmacist.
21.4.1.5. The dispensing pharmacist or pharmacist assistant signs the prescription.
21.4.1.6. A registered pharmacist verifies those prescriptions dispensed by pharmacist assistants and interns.
21.4.1.7. Medications are dispensed in a form requiring minimal manipulation.
21.5. Control and storage of medication

21.5.1. Medications are stored in a secure and clean environment.
Intent of 21.5.1
Secure storage systems ensure that pharmaceuticals and related substances are held under
conditions, which conform to statutory and the manufacturer's requirements.
Arrangements, including alarm systems, door access controls, and safes/vaults used to store
controlled medicines exist to ensure the security of medicines.
The pharmacy or pharmaceutical service stores and dispenses medications in a clean and secure
environment, which complies with laws, regulations and professional practice standards. In particular,
medications are clearly labelled, stored properly, and protected from heat, light and moisture, when
necessary.
Deep freeze, refrigeration, cold room and cool area facilities are provided for safe storage of certain
medications. There is a mechanism to ensure, that the temperature has been maintained throughout
the life of the medications. Deep freezers and refrigerators are defrosted when necessary. Doors,

hinges and seals are all functional.

Medications stored and dispensed from areas outside the pharmacy, for example patient care units,
comply with the same safety measures.
There is a registry, log or other mechanism to monitor and account for controlled substances.
21.5.1 Criteria
21.5.1.1. Medications are stored under conditions, as specified in current pharmaceutical Acts and regulations.
21.5.1.2. Hazardous and flammable materials are stored, in accordance with relevant regulations.
21.5.1.3. Separate designated storage areas, for the receipt and unpacking of incoming goods, are provided.
21.5.1.4. Separate designated storage areas, for materials under quarantine are provided, e.g. expired stock,
compounded products.
21.5.1.5. Medications are protected from theft and loss.
21.5.1.6. Secure storage facilities are available, including smoke detectors, alarm systems and barriers.
21.5.1.7. Stock control systems are managed in the pharmacy and other related departments.
21.5.1.8. A management information system is available, which provides accurate statistics relating to
pharmaceutical receipts and issues.
21.5.1.11. The cold chain is maintained for medications, where necessary.
21.5.1.12. Medication storage areas are protected from heat, light and moisture, and temperatures are
monitored and recorded.
21.5.1.13. Scheduled drugs, controlled by law, are stored in a cabinet of substantial construction, for which only
21.6. Quality management

pharmaceutical service.
Intent of 21.6.1
It is the responsibility of the management of the organisation to ensure, that standards are set
ensure, that standards are set for the particular department. This requires co-ordination with the
organisation's steering committee on quality. Departmental managers use available data and
information, to identify priority areas for quality monitoring and improvement.
21.6.1 Criteria
21.6.1.1. There is a written quality improvement programme for the pharmaceutical service, which has been
21.6.1.3. Indicators of performance are identified, to evaluate the quality of the service.
21.6.1.4. Processes are selected in order of priority, for evaluation and improvement.


21.7.1 Criteria

21.8.1 Criteria
21.8.1.3. Individuals, who collect specimens, are trained in the proper collection and handling of microbiological
specimens.
infection control.

21.9.1 Criteria
safety programme.
21.9.1.2. There is a programme for the inspection of pharmacy buildings and a plan to reduce fire risks for the
protection of patients, staff and visitors.
21.9.1.4. There is a procedure for the handling, storage and disposal of hazardous waste.
visitors.


Ambulatory care
22.Emergency Care
Overview of Emergency Care

setting that supports and responds to each patient's unique needs, requires a high level of planning
and co-ordination.
monitoring the patient, to understand the results of the care, modifying care when necessary and
laws and regulations, an individual's particular skills, knowledge and experience, and organisational
curative or rehabilitative and may include the use of anaesthesia, surgery, medications, supportive
therapies, or a combination of these. A plan of care is not sufficient to achieve optimal outcomes,
Continuity of care
using established criteria or policies, which determine the appropriateness of transfers within the
organisation.
Processes for the continuity and co-ordination of care among physicians, nurses and other healthcare
processes, and thus co-ordination of care.

Standards

patient's care.
Intent of 22.1.1
The individuals who bear overall responsibility for the patient's care or for a particular phase of care,
are identified in the patient's record, or in a manner that is made known to the staff.
22.1.1 Criteria
other staff.

providers.
Intent of 22.1.2
The co-ordination of patient care depends on the exchange of information between the members of
the multidisciplinary team. This can be through verbal, written or electronic means according to
appropriate policies determined by the organisation. Clinical leaders should use appropriate
techniques to better integrate and co-ordinate care for their patients (for example, team-delivered care,
multi-departmental patient care rounds, combined care planning forums, integrated patient records,
case managers). The process for working together will be simple and informal when the patient's
needs are not complex.
The patient, his/her family and others are included in the decision process when appropriate.
22.1.2 Criteria

Intent of 22.2.1
obtaining and documenting it, depend on the patient's needs and on the setting in which care is being

provided.
The organisation defines, in writing, the scope and content of assessments, to be performed by each
need for reassessment. It is essential that assessments be well-documented and that they can be
easily retrieved from the patient's record.
22.2.1 Criteria
ongoing care.
assessments.
unwanted variation.
Intent of 22.2.2
Regardless of the source, the scientific basis of guidelines should be reviewed and approved by the
organisational leaders and clinical practitioners, before implementation. This ensures that they meet
the criteria established by those leaders and are adapted to the community, patient needs and
organisational resources. Once implemented, guidelines are reviewed on a regular basis to ensure
their continued relevance.
22.2.2 Criteria

Intent of 22.2.3
22.2.3 Criteria
22.2.4. Each patient's assessment complies with current policies, procedures and
guidelines.

Intent of 22.2.4
The assessment of a patient is critical for the identification of the needs of the patient and the initiation
of the care process. Economic factors are assessed as part of the social assessment, particularly
when the patient and his or her family will be responsible for the cost of all or a portion of the care.
22.2.4 Criteria
22.2.4.1. Each patient has an assessment which meets organisation policy.
22.2.4.2. The assessment is appropriate to the patient's needs for emergency care.

Intent of 22.2.5
The preoperative anaesthetic assessment determines if the patient is a good candidate for the
assessment and the results of investigations must be available to the doctor performing the
assessment.
condition.
22.2.5 Criteria
22.2.5.5. The medical assessment is appropriate to the patients' needs and condition.
22.2.5.6. If surgery is to be performed, there is at least a brief note in the patient's record in a time frame that
meets organisation policy.

Intent of 22.2.6
A patient benefits most when the staff responsible for the patient work together, to analyse the
22.2.6 Criteria
patient's care.


22.3. Patient care

the ward.
Intent of 22.3.1
required include adequate office accommodation for the staff, sluice rooms which are hygienically
clean at all times, treatment and dressing rooms, and adequate storage space for clean linen.
Cleaning equipment is safely stored in a room or cupboard, used exclusively for this purpose.
There is at least one oxygen and one vacuum point for every 2 trolley spaces. Where there is no
piped oxygen and vacuum supply, there are mobile oxygen and vacuum pumps. All necessary fittings
for oxygen and suction are in place and working satisfactorily. Each trolley space is serviced by at
least one electrical socket outlet. Each ward is provided with a socket outlet, which is connected to the
Resuscitation equipment is immediately available from each section of the service. Resuscitation
• A defibrillator with adult and infant paddles
• An ECG monitor
• A CPR board
• Suction apparatus
• An Ambu bag or equivalent
• Oral airways
• Tracheotomy sets, where there is no theatre.
22.3.1 Criteria
22.3.1.6. Where there is a ward facility each patient has access to a nurse call system at all times.

record.
Intent of 22.3.2
Collaborative care and treatment team meetings, or similar patient discussions are recorded.
accessible, if they are to be acted upon in a timely manner. Locating orders on a common sheet, or in
a uniform location in patient records, facilitates the correct understanding and carrying out of orders.
When guidelines and other related tools are available, and relevant to the patient population and
22.3.2 Criteria
22.3.2.9. Re-assessments are documented in the patient's records.

Intent of 22.3.3
• identify patients with pain, during the initial assessment and at reassessments.
• communicate with, and provide education for, patients and their families about pain management
in the context of their personal, cultural and religious beliefs; and
• educate health care providers in pain assessment and management.
decisions.

22.3.3 Criteria
management of pain.
pain management.
Intent of 22.3.4
needs. Children and the elderly are commonly in this group, as they may not be able to speak for
themselves, understand the care process or participate in decisions regarding their care. Similarly,
the frightened, confused or comatose patient is unable to understand the care process, when care
needs to be provided efficiently and rapidly.
A variety of services are considered "high-risk", because of the complex equipment needed to treat a
life-threatening condition, the nature of the treatment (eg the use of blood and blood products) or the
potential for harm to the patient (eg restraint).
Of particular concern is that the policies or procedures must identify:
• any special consent considerations;
• any monitoring requirements;
• the special qualifications or skills of staff involved in the care process; and
• the availability and use of resuscitation equipment, including that for children.
Monitoring provides the information needed to ensure, that the policies and procedures are adequately
22.3.4 Criteria
damaged container).
22.3.4.5. Policies and procedures guide the care of patients who are comatose.
22.3.4.8. Policies and procedures guide the care of patients who have communicable diseases.

Intent of 22.3.5
some other mechanism. Patients and their families understand who may, in addition to the patient,
give consent. Designated staff are trained to inform patients and to obtain and document patient
consent. These staff members clearly explain any proposed treatments or procedures to the patient
and, when appropriate, the family. Informed consent includes:
• an explanation of the risks and benefits of the planned procedure(s);
• consideration of the surgical and non-surgical options, available to treat the patient.
discussed.
documentation of the patient's verbal consent in the patient's record, by the individual who provided
the information for the consent. Documentation includes the statement that the patient acknowledged
full understanding of the information. The patient's surgeon or other qualified individual provides the
22.3.5 Criteria
verbal consent.
22.4. Medication
regulations.

Intent of 22.4.1
Medication management is not only the responsibility of the pharmaceutical service, but also of the
Each organisation has the responsibility to identify those individuals with the requisite knowledge and
experience, and who are permitted by laws, regulations or registration to prescribe or order
prescribed and for using verbal medication orders is defined in policy.
22.4.1 Criteria
patient care unit.
individuals.

Intent of 22.4.2
Only staff who are suitably trained and experienced may administer medications to patients. The
The patient, physician, nurse and other care providers work together, to monitor patients on
The organisation identifies adverse effects, which are to be recorded and those that must be reported
medication errors, through understanding the types of errors that occur. Improvements in medication
staff training.
22.4.2 Criteria
medications.
22.4.2.3. Medications are checked against the original prescriptions and are administered as prescribed.
22.4.2.6. The organisation has identified those adverse effects that are to be recorded in the patient's record



Intent of 22.4.3
Patient care units store medications in a clean and secure environment, which complies with law,
22.4.3 Criteria
humidity.
date.

Intent of 22.5.1
22.5.1 Criteria
22.5.1.4. The record of the patient accompanies the patient when he or she is transferred within the
organisation.

Intent of 22.5.2
medical supervision. The process of transferring the patient must consider transportation needs. The


22.5.2 Criteria
transferred.
organisation.
patient's record.

Intent of 22.5.3
The organisation begins to plan for the patient's continuing care needs as early in the care process as
22.5.3 Criteria
22.5.3.6. Patients and, as appropriate, their families, are given understandable follow-up instructions in writing
care.
22.5.4. A discharge summary is written for each patient, and made available in the
patient's record.
Intent of 22.5.4
The discharge summary is one of the most important documents, to ensure continuity of care and
22.5.4 Criteria
22.5.4.1. A discharge summary is written by medical practitioner, at the discharge of each patient.



emergency service.
Intent of 22.6.1
22.6.1 Criteria
22.6.1.1. There is a written quality improvement programme for the emergency service that is developed and
and care.

22.7.1 Criteria


22.8.1 Criteria
specimens.
infection control.

22.9.1. The organisation controls and directs risk management programmes, which
22.9.1 Criteria
safety programme.
and visitors.


23.Outpatient Care
Overview of Outpatient Care

and co-ordination.
Continuity of care
organisation.
Processes, for continuity and co-ordination of care among physicians, nurses and other healthcare
providers, must be implemented in and between all services.
Leaders of various settings and services work together, to design and implement the required
processes, and thus ensure co-ordination of care.

Standards

patient's care.
Intent of 23.1.1
23.1.1 Criteria
other staff.

providers.
Intent of 23.1.2
The co-ordination of patient care depends on the exchange of information between the various
members of the multidisciplinary team. This can be through verbal, written or electronic means
according to appropriate policies determined by the organisation. Clinical leaders should use
appropriate techniques, to better integrate and co-ordinate care for their patients (for example, team-
delivered care, combined care planning forums, integrated patient records, case managers). The
process for working together will be simple and informal when the patient's needs are not complex.
23.1.2 Criteria
23.1.2.5. Information exchanged includes summary of the care provided.

Intent of 23.2.1

provided.
23.2.1 Criteria
ongoing care.
assessments.
23.2.1.4. The findings of assessments performed outside the organisation are verified.
unwanted variation.
Intent of 23.2.2
organisational leaders and clinical practitioners before implementation. This ensures that they meet
23.2.2 Criteria
Intent of 23.2.3
initiation of the care process. Patients' social, cultural and family status are important factors, which
can influence their response to illness and care. Families can be of considerable help in these areas of
assessment and in understanding the patient's wishes and preferences. Economic factors are
assessed as part of the social assessment, particularly when the patient and his or her family will be
responsible for the cost of all or a portion of the care.
Functional and nutritional assessments allow for the patient to be referred for specialist care if
necessary.

culture of the patient population, and involves the family, when appropriate.
The outcome of the patient's initial assessment is an understanding of the patient's medical and
nursing needs, so that care and treatment can begin.
23.2.3 Criteria
23.2.3.1. Each patient has an initial assessment which meets organisation policy.

Intent of 23.2.4
23.2.4 Criteria
patient's care.
23.3. Patient care

23.3.1. The outpatient department is equipped and managed to provide an effective
service.
Intent of 23.3.1
required include adequate office accommodation for staff.

Cleaning equipment is safely stored in a room or cupboard, used expressly for this purpose. There are
adequate toilets for staff and patients.
Lighting and ventilation are adequate.
Resuscitation equipment is immediately available.
23.3.1 Criteria
23.3.1.2. The outpatient department has adequate light and ventilation.
23.3.1.3. Medical equipment is maintained in accordance with the organisation's policies.
23.3.1.5. Electricity and water are available in accordance with the policies of the organisation.
23.3.2. There is a system to ensure that patients are seen within the shortest
possible time.
Intent of 23.3.2
Patients have the right to be attended to within the shortest possible time. There is an appointment
system, and patients who are waiting, are advised of any delays that may be experienced in receiving
attention. The waiting times are monitored as part of the organisation's quality management and
23.3.2 Criteria
23.3.2.1. There is an appointment system for patients.
23.3.2.2. Patients who are waiting are advised of any delays that may be experienced in receiving attention.
23.3.2.3. There is a system for accommodating urgent cases without disrupting the appointment times.
23.3.2.4. There is a system for accommodating the elderly and frail, and pregnant women, without disrupting
the appointment times.
23.3.2.5. Waiting times are monitored as part of the organisation's quality management and improvement
programme.
record.
Intent of 23.3.3
Collaborative care and treatment team meetings, or similar patient discussions, are recorded.
Individuals, qualified to do so, order diagnostic and other procedures. These orders must be easily
accessible, if they are to be acted on in a timely manner. Locating orders on a common sheet, or in a
of the organisation and to train staff to use them.

23.3.3 Criteria

Intent of 23.3.4
• identify patients with pain, during the initial assessment and at reassessments;
23.3.4 Criteria
management of pain.
pain management.
Intent of 23.3.5
themselves, understand the care process or participate in decisions regarding their care. Similarly, the
frightened, confused or comatose patient is unable to understand the care process, when care needs
to be provided efficiently and rapidly.
life-threatening condition, the nature of the treatment or the potential for harm to the patient.
Policies and procedures are important, for staff to understand these patients and services, and to


23.3.5 Criteria
23.3.5.3. Policies and procedures guide the care of patients with communicable diseases and
immunosuppressed patients.
Intent of 23.3.6
decisions. Patients and their families are informed as to what tests, procedures and treatments require
discussed.
23.3.6 Criteria

verbal consent.
23.4. Medication
regulations.
Intent of 23.4.1
Medication management is not only the responsibility of the pharmaceutical service but also of the
experience, and who are permitted by laws, regulations, or registration to prescribe or order
23.4.1 Criteria
patient care unit.
individuals.

Intent of 23.4.2

medication errors through understanding the types of errors, that occur. Improvements in medication
staff training.
23.4.2 Criteria
medications.

Intent of 23.4.3
regulation and professional practice standards.
23.4.3 Criteria
humidity.
date.

record.
Intent of 23.5.1
Each organisation decides on the placement and format of educational assessment, planning and

Education is provided, to support care decisions of patients and their families. In addition, when a
patient or his/her family directly participate in providing care, for example changing dressings, feeding
and administration, they need to be educated.
On occasion, it is important that they be made aware of any financial implications associated with care
choices.
Education in areas, which carry high risk to patients, is routinely provided by the organisation, for
instance the safe and effective use of medications and medical equipment.
Community organisations, which support health promotion and disease prevention education, are
23.5.1 Criteria
preferences.
Intent of 23.5.2
Learning occurs, when attention is paid to the methods used to educate patients and their families.
The organisation selects appropriate educational methods and people to provide the education.
Staff collaboration helps to ensure that the information patients and their families receive is
comprehensive, consistent, and as effective as possible.
23.5.2 Criteria
23.5.2.4. Interaction between staff, the patient and family confirms that the information was understood and is
noted in the patient's record.

Intent of 23.6.1
23.6.1 Criteria

organisation.

Intent of 23.6.2
23.6.2 Criteria
transferred.
organisation.
patient's record.

outpatient service.
Intent of 23.7.1
23.7.1 Criteria
23.7.1.1. There is a written quality improvement programme for the outpatient service that is developed and

and care.

23.8.1 Criteria

23.9.1 Criteria
specimens.
infection control.
23.9.1.5. The department provides education on infection control practices to staff, patients and, as
appropriate, the family and other care givers.

23.10.1. The organisation directs and control risk management programmes, which
23.10.1 Criteria
safety programme.
and visitors.



24.Ambulatory Care
Overview of Ambulatory Care

Ambulatory care is care and treatment provided on an outpatient basis and does not include a stay of
longer than 24 hours. Ambulatory care may be an integral part of the continuum of care provided
before or after a period of hospitalization, or may be provided to a patient, who is referred from a
community-based organization. In some organizations, ambulatory care may be considered an
independent, comprehensive service encompassing all ambulatory visits.
The World Health Organisation (WHO) has outlined a framework for primary health care, which
includes preventive, promotive, curative, rehabilitative and supportive components. Community Health
Service programmes encompass these five components, within the continuum of health care for local
communities. A comprehensive referral network with other community agencies supports continuity of
care in terms of primary health care services, ambulatory care at a local hospital, educational services
and social services.
and co-ordination.
assessing patients to monitor the results of care, modifying care when necessary and completing the
follow-up.
curative or rehabilitative and may include the use of anaesthesia, surgery, medications, supportive
organisation.
providers, must be implemented in and between all services. Leaders of various settings and services
work together, to design and implement the required processes, and thus ensure co-ordination of care.


Standards
24.1. Organisation and co-ordination

24.1.1. The ambulatory care service is organised to provide a safe and effective
service and is co-ordinated with other relevant services in the hospital and in the
community.
24.1.1 Criteria
24.1.1.1. There are mechanisms which allow for community consultation and participation regarding the goals
and activities of the various services/programmes.
24.1.1.2. The lines of communication between the hospital and community services are clearly defined.
24.1.1.3. Relations are established, and contact maintained with other relevant services and agencies including
both government and non-government agencies.
24.1.1.4. The range of services offered by the organisation and its hours of operation are clearly defined and
communicated to the public and relevant organisations.
24.1.1.5. Emergency services are provided twenty-four hours per day every day of the year.
24.1.1.6. The service is organised in terms of personnel, facilities, equipment, and procedures to evaluate,
manage, stabilise and transfer patients with emergency conditions.
24.1.1.7. Arrangements are in place to assure that adequate speciality consultation services are available.
24.1.1.8. Laboratory and radiology services are available to meet the needs of patients.
possible time.
Intent of 24.1.2
improvement programme. Patients requiring urgent care are identified and attended to immediately.
24.1.2 Criteria
24.1.2.1. There is a process of patient registration for ambulatory care and treatment.
24.1.2.2. A patient register is maintained for all patient attendances.
24.1.2.3. For emergency patients the register contains at least the patient's name, date and time of admission,
discharge, referral or death, and the treatment administered.
24.1.2.5. Patients seeking immediate/urgent care services are seen without prior appointments.
24.1.2.7. Waiting lists are regularly reviewed and revised in accordance with changing client/patient needs.
24.1.2.8. Patients who are waiting are advised of any delays that may be experienced in receiving attention.
24.1.2.9. Waiting times are monitored as part of the organisation's quality management and improvement
programme.
24.2. Staffing
patient's care.
Intent of 24.2.1
The individuals who bear overall responsibility for the patient's care, or for a particular phase of care
are identified in the patient's record, or in a manner that is made known to the staff.

24.2.1 Criteria
other staff.
24.2.1.4. During hours of operation there is an adequate number of medical practitioners available to provide
continuous medical cover to all sections at all times.
24.2.1.5. Medical cover is reflected on a roster and each practitioner on the roster is contactable by telephone
or pager, or other two-way communication method.
24.2.1.6. If not able to be available, then a medical practitioner nominates a similarly suitable doctor to cover in
his/her absence.
24.2.1.7. Personnel assisting in the provision of emergency services are appropriately qualified, trained and
supervised and are available in sufficient numbers for the emergency services provided.
24.2.1.8. All emergency services personnel maintain skills in basic cardiac life support.
24.2.1.9. At least one appropriately qualified medical practitioner is present at all times and immediately
available to attend to emergencies.
24.2.1.10. Nursing staff allocation ensures that appropriate nursing expertise and experience is available at all
times to ensure continuity of care.

24.3.1. There are current written policies and procedures for the management and
activities of the ambulatory care service, which reflect current legislation, standards of
practice and the objectives of the service and the hospital.
Intent of 24.3.1
Leaders must ensure that all service-related activities are guided by documented policies and
procedures and that these are kept updated. Co-ordination of clinical services comes from an
understanding of the services and collaboration among all service providers in the development of
policies and procedures. Policies and procedures are used to guide all patient care activities and staff
are trained in the correct use of these policies. Service-related activities are evaluated against the
standards set in these policy documents.
24.3.1 Criteria
24.3.1.1. Policies and procedures are available to guide staff in management and clinical aspects of the
service.
24.3.1.2. Staff are trained in, and use the policies and procedures to guide care.
24.3.1.4. Policies and procedures relate to the appointment system.
24.3.1.5. Policies and procedures relate to obtaining and presenting records before appointment.
24.3.1.6. Policies and procedures relate to the hours during which routine and after hour services are offered.
24.3.1.7. Policies and procedures relate to assessing patients on admission and during ongoing care.
24.3.1.8. Policies and procedures relate to the use of restraint and care of patients in restraint.
24.3.1.9. Policies and procedures relate to psychiatric emergencies
24.3.1.10. Policies and procedures relate to non-accidental injury to children
24.3.1.11. Policies and procedures relate to police enquiries
24.3.1.12. Policies and procedures relate to social violence
24.3.1.13. Policies and procedures relate to domestic violence.
24.3.1.14. Policies and procedures relate to the management of rape cases.
24.3.1.15. Policies and procedures relate to dealing with coroners' cases
24.3.1.16. Policies and procedures relate to summoning help in a medical emergency.
24.3.1.17. Policies and procedures relate to summoning help for security assistance.
24.3.1.18. Policies and procedures relate to the holding area and observation of patients.

24.3.1.19. Policies and procedures relate to the transfer of patients to

other institutions.
24.3.1.20. Policies and procedures relate to the discharge of patients or
referral to consultants, other agencies or institutions.
Intent of 24.3.2
themselves, understand the care process or participate in decisions regarding their care. Similarly,
the frightened, confused or comatose patient is unable to understand the care process when care
needs to be provided efficiently and rapidly.
life-threatening condition, the nature of the treatment or the potential for harm to the patient.
Policies and procedures are important, for staff to understand these patients and services, and to
• render compassionate care to those in pain;
educate healthcare providers in pain assessment and management.
24.3.2 Criteria
24.3.2.2. Policies and procedures guide the care of emergency patients.
24.3.2.3. Policies and procedures guide the care of patients with communicable diseases and
immunosuppressed patients.
24.3.2.5. Policies and procedures guide the care of patients in pain.


24.3.2.7. Policies and procedures guide the care of patients who are comatose or on life support.
24.3.2.8. Policies and procedures relate to the handling, use and administration of blood and blood products.
24.3.2.9. Policies and procedures relate to management of contaminated blood supplies (expired, opened or
damaged container).
24.3.2.10. Policies and procedures relate to conscious sedation.
24.3.2.11. Policies and procedures relate to procedures performed under
local anaesthesia.
24.3.2.12. Policies and procedures relate to minor suturing.
24.4. Recording of patient care

24.4.1. There is a clinical record for each patient, which contains sufficient
information to identify the patient, support the diagnosis, justify the treatment,
document the course and results of treatment, and promote continuity of care among
health care providers.
24.4.1 Criteria
24.4.1.1. Clinical records contain adequate information to support the diagnosis.
24.4.1.2. Clinical records contain adequate information to justify the care and treatment.
24.4.1.3. Clinical records contain adequate information to provide a summary of the care provided.
24.4.1.4. Clinical records contain adequate information to reflect the patient's progress.
24.4.1.5. Clinical records are up to date to ensure the transfer of the latest information and promote continuity.
24.4.1.8. When required by the organisation, the time of an entry can be identified
24.4.1.9. Clinical records of emergency patients include the time of arrival.
24.4.1.10. Clinical records of emergency patients include time of referral to medical practitioner,
24.4.1.11. Clinical records of emergency patients include time seen by the medical practitioner.
24.4.1.12. Clinical records of emergency patients include conclusions at the termination of treatment
24.4.1.13. Clinical records of emergency patients include patient's condition at discharge
24.4.1.18. Clinical records of all patients include any follow-up care instructions.

identified through an established initial assessment process which complies with
current policies, procedures and guidelines.
Intent of 24.5.1
When a patient enters the service, the specific information required and the procedures for obtaining
and documenting it depend on the patient's needs and on the setting in which care is being provided.

easily retrieved from the patient's record. The initial assessment of a patient is critical for the
identification of the needs of the patient and initiation of the care process. Patients' social, cultural and
family status are important factors, which can influence their response to illness and care. Families can
be of considerable help in these areas of assessment and in understanding the patient's wishes and
preferences. Economic factors are assessed as part of the social assessment, particularly when the
patient and his or her family will be responsible for the cost of all or a portion of the care.
Functional and nutritional assessment allows for the patient to be referred for specialist care, if
necessary.
When the clinical assessment was conducted outside the organisation, a legible copy is placed in the
24.5.1 Criteria
assessments.
24.5.1.3. Each patient has an initial assessment, which meets organisation policy.
24.5.1.6. The initial assessment includes functional and nutritional assessment as applicable.
24.5.1.7. The initial assessment includes psychological assessment as applicable.
24.5.1.8. The initial assessment includes social and cultural assessment as applicable.
24.5.1.12. The initial assessment results in the identification of the patient's health care needs.
24.5.1.13. Patients in pain are identified during the assessment process.
24.5.1.14. Any significant changes in the patient's condition are noted in the patient's record.
24.5.1.16. Assessment findings are documented in the patient's record.

Intent of 24.5.2
24.5.2 Criteria
24.5.2.1. Documented assessment findings are readily available to those responsible for the patient's care.

patient's care.
24.6. Delivery of care

24.6.1. The care provided to each patient is planned and co-ordinated among care
providers.
Intent of 24.6.1
Collaborative care and treatment team discussions are recorded. Individuals qualified to do so order
diagnostic and other procedures. These orders must be easily accessible if they are to be acted upon
in a timely manner. Locating orders on a common sheet or in a uniform location in patient records
facilitates the correct understanding and carrying out of orders.
The co-ordination of patient care depends on the exchange of information between the members of the
appropriate policies determined by the organisation. Clinical leaders should use appropriate
techniques to better integrate and co-ordinate care for their patients (for example, team-delivered care,
combined care-planning fora, integrated patient records, case managers). The process for working
together will be simple and informal when the patient's needs are not complex.
available to all relevant caregivers who are authorised to have access to its contents.
24.6.1 Criteria
24.6.1.1. Clinical practice guidelines relevant to the patients and services of the organisation are used to guide
patient care processes.
24.6.1.2. Clinical pathways, relevant to the organisation's patients and services, are used to standardise care
processes.

Intent of 24.6.2
decisions. The information is provided to patients in a clear and understandable way, and patients and
their families participate in care decisions to the extent they choose. They are informed as to what
tests, procedures and treatments require consent and how they can give consent, for example
verbally, by signing a consent form, or through some other mechanism. Patients and their families
understand who may, in addition to the patient, give consent. Designated staff are trained to inform
patients and to obtain and document patient consent. These staff members clearly explain any
proposed treatments or procedures to the patient and, when appropriate, the family. Informed consent
includes:
• an explanation of the risks and benefits of the planned procedures;
• consideration of the surgical and non-surgical options, available to treat the patient.
discussed.
information for the consent. Documentation includes the statement that the patient acknowledged full
24.6.2 Criteria
verbal consent.
24.7. Medication
regulations.
Intent of 24.7.1

experience, and who are permitted by laws, regulations or registration to prescribe or order
24.7.1 Criteria
24.7.1.1. Policies and procedures guide the safe prescribing, ordering, administration, and dispensing of
medications in the ambulatory care service.
24.7.1.3. Relevant staff are trained in correct prescribing, ordering, administration and dispensing practices.
24.7.1.5. Only those permitted by the organisation and by relevant laws and regulations dispense medications.
individuals.

Intent of 24.7.2
staff training.
24.7.2 Criteria
medications.
24.7.2.2. There is evidence that patients are identified before medication is administered.

Intent of 24.7.3
Patient care units store medications in a clean and secure environment, which complies with laws,
regulations and professional practice standards.
24.7.3 Criteria
humidity.
date.

record.
Intent of 24.8.1
make care decisions, participate in care, and continue care at home. Variables like educational
literacy, beliefs and limitations are taken into account.
Education is provided to support care decisions of patients and their families. In addition, when a
choices.
Education in areas, which carry high risk to patients is routinely provided by the organisation, for
Community organisations, which support health promotion and disease prevention education are
24.8.1 Criteria
preferences.

Intent of 24.8.2
Learning occurs when attention is paid to the methods used to educate patients and their families. The
24.8.2 Criteria

Intent of 24.9.1
Patients frequently move between various care settings within the organisation . Without co-
ordination and effective transfer of information and responsibilities, errors of omission and commission
may occur, exposing the patient to avoidable risks.
24.9.1 Criteria
24.9.1.1. Established criteria or policies determine the appropriateness of transfers/referrals within the
organisation.
organisation.

Intent of 24.9.2
inpatient services such as sub-acute care or long-term rehabilitation.
24.9.2 Criteria
transferred.

organisation.
24.9.2.11. The following are noted in patient's record the reason(s) for the transfer.
24.9.2.12. The following are noted in patient's record any special conditions related to transfer.
24.9.2.13. The following are noted in patient's record the condition of the patient before transfer.
24.9.2.14. The following are noted in patient's record the healthcare organisation or other internal unit agreeing
to receive the patient.
24.9.3. There is a process to appropriately discharge, or refer patients to another

organisation to meet their continuing needs.
Intent of 24.9.3
When patients are discharged or referred to another organisation (e.g. primary health care clinic,
community-based organisation, another hospital, or private practitioner), these service providers as
well as the patients (and their families, as appropriate) are provided with written details to ensure
continuity of care and to facilitate the correct management at subsequent visits.
24.9.3 Criteria
24.9.3.1. There is a process for referring patients to other organisations, based on the patient's need for care.
24.9.3.3. A letter of referral accompanies the patient.
24.9.3.4. The referral is recorded.
24.9.3.5. Patients and, as appropriate their families, are given understandable follow-up instructions.
care.
24.9.3.7. Follow-up instructions are recorded in the patient's record.
24.10. Facilities and equipment

24.10.1. The ambulatory care service is equipped and managed to provide an
effective service.
Intent of 24.10.1
In order to provide safe patient care, the service requires adequate resources. The physical facilities
24.10.1 Criteria
24.10.1.2. Services are clearly signposted from the street as well as within the building.
24.10.1.3. Sign-posting of location of services within the building is appropriate (having regard to the need for
patients' anonymity and right to privacy).
24.10.1.4. The unit has a weather protected external entrance with direct ambulance access.

24.10.1.5. There is a security system to prevent unauthorized individuals entering the unit.
24.10.1.6. There is an emergency call system for summoning of security assistance.
24.10.1.7. There is space and seating accommodation for patients who are waiting to be attended to.
24.10.1.8. There are notice boards with relevant information e.g. payment details, transport arrangements.
24.10.1.9. There is an adequate number of clean toilets and hand washing facilities
24.10.1.1 Toilets and hand washing facilities are clearly sign-posted.
0.
24.10.1.1 An adequate number of suitable refuse containers are provided in all areas.
1.
24.10.1.1 There are adequate consulting rooms/bays for each health professional to provide care in privacy.
2.
24.10.1.1 Equipment, drugs and other agents necessary to provide immediate/urgent care services are
3. available.
24.10.1.1 Emergency resuscitation equipment and drugs for adult and
4. paediatric use are easily accessible from every section of the ambulatory service.
24.10.1.1 There is an emergency call system for summoning of medical assistance.
5.
24.10.1.1 Medical equipment is maintained in accordance with the organisation's policies.
6.
24.10.1.1 The ambulatory care department has adequate light and ventilation.
7.
24.10.1.1 Electricity and water are available in accordance with the policies of the organisation.
8.

ambulatory care service.
Intent of 24.11.1
24.11.1 Criteria
24.11.1.1. There is a written quality improvement programme for the ambulatory service that is developed and
and care.

24.12.1 Criteria

management of pain.
pain management.

24.13.1 Criteria
specimens.
infection control.

24.14.1 Criteria
safety programme.
24.14.1.5. There is a plan that is implemented for the safeguarding and protection of buildings, staff and visitors.


ANCILLARY SERVICES
25.Sterilising and Disinfecting Unit
Overview of Sterilising and Disinfecting Unit

This chapter is designed to enable the staff in the particular service to assess, monitor and improve
the quality of care in their own service.
The manager of the service works with other organisational leaders and managers to improve the
quality of care throughout the organisation, and ensures that the unit complies with criteria relating to
management, leadership, human resource development, infection control, environmental safety and
quality improvement. This chapter therefore strengthens the standards in previous chapters, but
cannot be used in isolation.

Standards
25.1. Management
25.1.1. The SDU is managed to ensure the provision of a safe and effective service.
Intent of 25.1.1
Departmental and service managers are primarily responsible for ensuring, that the mission of the
organisation is met, through the provision of management and leadership at departmental level. Good
departmental or service performances require clear leadership from a suitably qualified individual.
The responsibilities of each role in the department are defined in writing. Documents prepared by
each department define its goals, as well as identifying current and planned services. Lines of
communication within each department are documented to ensure clear accountability.
25.1.1 Criteria
25.1.1.1. A person who is suitably qualified and experienced manages the unit.
25.1.1.2. This individual has appropriate training, education and experience to manage the unit.
25.1.1.3. The manager is responsible for the day-to-day operation of the unit.
25.1.1.4. The manager plans and implements an effective organisational structure to support his/her
responsibilities and authority.
25.1.1.5. The manager is identified by title or post.
25.1.1.6. The responsibilities of the unit manager are defined in writing.
25.2. Staffing
25.2.1. There are an adequate number of suitably qualified and competent staff to
Intent of 25.2.1
Departmental policies and procedures reflect the knowledge, skills and availability of staff, required to
provide an effective service. Orientation and induction programmes assure the competence of staff,
before they begin to carry out their functions.
Staff act in accordance with job descriptions, and are evaluated in accordance with their assigned
responsibilities. The needs for in-service training of staff in the service are continuously assessed and
appropriate training is provided, to ensure a safe and effective service.
25.2.1 Criteria
25.2.1.1. Staff members in the unit have a written job description which defines their responsibilities.
25.2.1.2. Staff in the unit receive regular in-service training on sterilising and disinfecting processes.
25.2.1.3. There is at least one documented evaluation of staff each year, or more frequently, as defined by the
organisation.
25.2.1.6. The manager has established an orientation and induction programme for service staff.

25.3.1. The unit is designed to allow for effective sterilising and disinfecting of
equipment and supplies.

Intent of 25.3.1
Departmental managers need to work closely with organisational managers, to ensure that facilities
and equipment are adequate. Departmental managers keep organisational managers informed of
facilities, which are inadequate, additional equipment requirements, and the current state of facilities
and equipment.
25.3.1 Criteria
25.3.1.1. The design of the sterilising and disinfecting unit and the layout of equipment ensures flow of work
from the soiled to the clean side of the unit.
25.3.1.2. There is a washing and decontamination area with stainless steel sinks and hot and cold running
water, and a sanitary sewage system.
25.3.1.3. The washing and decontamination area has facilities with hot and cold water to wash trolleys.
25.3.1.4. There is a pre-packing area with storage facilities for clean materials.
25.3.1.5. There is a storage area for sterile packs with racks that allow for circulation of air.
25.3.1.6. There is adequate light and ventilation.
25.3.1.7. There is a well-ventilated room/cupboard for the storage of sterile supplies.
25.3.2. Sterilising equipment is suited to its use.

Intent of 25.3.2
There are many methods of sterilising equipment. Whatever methods are used, staff need to ensure
that the equipment used is effective. Systems must, therefore, be in place which ensure that sterility is
obtained through the sterilisation processes.
25.3.2 Criteria
25.3.2.1. There are one or more autoclaves or their equivalents capable of sterilising porous loads (gowns,
drapes and dressings), as well as wrapped and unwrapped instruments.
25.3.2.2. Autoclaves are appropriate to their use and manufacturer's instructions are complied with.
25.3.2.3. Where liquids are sterilised, an autoclave with a fluid cycle and a reverse osmosis or distillation plant
is also provided.
25.3.2.4. Where ethylene oxide is used as a sterilant, the installation complies with relevant safety standards
and legislation.
25.3.2.5. Autoclave sterility is tested daily and results recorded.
25.3.2.6. The sterility of each pack is shown on indicator tapes, which are suited to the processes used.
25.3.2.7. There is an internal and external autoclave trolley.
25.3.3. The sterility of equipment and supplies is maintained.

Intent of 25.3.3
Once sterility has been obtained, it is possible that this sterility may be lost in the storage, issue or
distribution of sterile supplies. Systems need to be in place to ensure that packages reach the user
sterile and intact.
25.3.3 Criteria
25.3.3.1. There is a mechanism to ensure that sterile supplies in stock are dated and used on a first in, first out
basis.
25.3.3.2. The maintenance of sterility is checked before any sterile packaging is opened.
25.3.3.3. There is a system for the ordering, storage, maintenance and distribution of sterile supplies.

25.4.1. Policies and procedures guide the management of the unit.

Intent of 25.4.1
Policies and procedures are essential in a department, to ensure that staff receive guidance in the
functions carried out. Departmental policies may be standardised for similar departments, or unique to
the particular department. They need to be indexed, available, signed, dated, and have the authority
of the organisational leaders. A system needs to be in place to ensure that departmental policies and
procedures are known and implemented.
25.4.1 Criteria
25.4.1.1. The manager ensures that policies and procedures are available to guide the unit.
25.4.1.3. Policies and procedures are compiled in a comprehensive manual, which is indexed and easily
25.4.1.4. Each policy and procedure is reviewed, dated and signed.
25.4.1.6. Policies and procedures are available relating to the processes for cleaning sterilising equipment.
25.4.1.7. Policies and procedures are available relating to ordering of sterile supplies from suppliers.
25.4.1.8. Policies and procedures are developed relating to receiving, checking and packing supplies received
from suppliers.
25.4.1.9. Policies and procedures are available relating to the storage of sterile supplies.
25.4.1.10. Policies and procedures are available relating to recording issues of stock and maintaining stock
levels.
25.4.1.11. Policies and procedures are available relating to ensuring that supplies are kept sterile.
25.4.1.12. Policies and procedures are available relating to acting on incidents where the sterility of supplies has
not been maintained.
25.4.1.13. Policies and procedures are available relating to the provision of emergency and after-hour sterile
supply/sterilisation services.
25.4.1.14. Policies and procedures are available relating to the safe use of SDU equipment, including
autoclaves.
25.4.1.15. Policies and procedures are available relating to the sterilisation of liquids and the use of ethylene
oxide.

sterilising and disinfecting unit.
Intent of 25.5.1
to ensure that standards are set for that particular department. This requires co-ordination with the
25.5.1 Criteria
25.5.1.2. Processes relating to service provision are selected in order of priority for evaluation and
improvement.
25.5.1.4. Incidents relating to loss of sterility are recorded and acted upon using quality improvement
methodology.
25.5.1.5. Data is available to demonstrate that improvements are sustained.


25.6.1 Criteria
specimens.
infection control.
25.6.1.5. The department provides education on infection control practices to staff.

25.7.1 Criteria
safety programme.


26.Food Service
Overview of Food Service

quality in their own service.
The manager of the service works with other organisational leaders and managers to improve quality
of care throughout the organisation, and to ensure that the food service complies with criteria relating
to management, leadership, human resource development, infection control, environmental safety and
quality improvement. This chapter, therefore, strengthens the standards in previous chapters, but
cannot be used in isolation.

Standards
26.1. Management
26.1.1. The food service is managed to ensure the provision of a safe and effective
service.
Intent of 26.1.1
The responsibilities of each role in the department are defined in writing. Documents prepared by
each department define its goals, as well as identifying current and planned services. Lines of
communication within each department are documented to ensure clear accountability.
26.1.1 Criteria
26.1.1.1. A person who is suitably qualified and experienced manages the service.
26.1.1.2. This individual has appropriate training, education and experience to manage the department.
26.1.1.3. The manager is responsible for the day-to-day operation of the service.
26.1.1.6. The responsibilities of the manager are defined in writing.
26.2. Staffing
Intent of 26.2.1
provide an effective service. Orientation and induction programmes assure the competence of staff
responsibilities. The in-service training needs of staff in the service are continuously assessed and
26.2.1 Criteria
26.2.1.1. Staff members employed in the service have a written job description which defines their
responsibilities.
26.2.1.2. Staff in the service receive regular in-service training on food management procedures.
organisation.
26.3. Physical facilities

26.3.1. The department is designed to allow for the effective storage, preparation
and serving of food.

Intent of 26.3.1
Departmental managers need to work closely with organisational managers, to ensure that facilities
and equipment.
26.3.1 Criteria
26.3.1.1. There are separate hand-washing facilities in the food preparation area, with soap and paper towels.
26.3.1.2. There are lockers for food handlers for their outer clothing.
26.3.1.3. Personnel are constantly reminded of the importance of effective hand washing (ie posters).
26.3.1.4. An adequate number of suitable refuse containers are provided in or near each change room, hand-
washing facility and toilet area.
26.3.1.5. There are adequate, suitable and conveniently placed change rooms, toilets and ablution facilities for
food handlers.
26.3.1.6. Ablution and change facilities are well lit and well ventilated.
26.3.1.7. Ablution facilities are kept clean.
26.3.1.8. Preparation surfaces are cleaned and dried between use for different activities.
26.3.1.9. There is a mechanism to prevent unauthorised individuals from entering food preparation areas.
26.3.1.10. The temperature, ventilation and humidity levels are controlled for satisfactory working and
cleanliness.
26.3.1.11. Windows in the preparation area have fly screens or another effective method of fly control.
26.3.1.12. Floors, walls and ceilings are clean.
26.3.1.14. There is a fire extinguisher and a fire blanket in the kitchen.
26.3.1.15. The food service area meets with health and safety regulations.
26.4. Menu planning

26.4.1. Menus are planned and meals are acceptably presented.
Intent of 26.4.1
Menus may be planned by an outsourced organisation, a dietician employed by the organisation, or
other individuals with acceptable food management qualifications and suitable experience.
26.4.1 Criteria
26.4.1.1. A suitably qualified person advises on meal development.
26.4.1.2. There is a planned weekly menu suitable for different seasons.
26.4.1.3. Patients are provided with at least three meals per day.
26.4.1.4. Wherever possible, patient food preferences are respected and substitutions made available.
26.4.1.5. Cultural preferences are taken into account.
26.4.1.6. The nutritional needs of edentulous patients and geriatric patients are considered.
26.4.1.7. Meals are presented in an attractive manner.
26.4.1.8. No more than 14 hours elapse between the serving of the evening meal and the next substantial
meal.

26.5.1. Policies and procedures guide the management of the service.
Intent of 26.5.1
functions carried out. Departmental policies may be standardised for similar departments or unique to
the particular department. They need to be indexed, available, signed, dated and have the authority of

the organisational leaders. A system needs to be in place to ensure, that departmental policies and
26.5.1 Criteria
26.5.1.1. The departmental manager ensures that policies and procedures are available to guide the
department.
26.5.1.5. Policies and procedures are available relating to the wearing of jewellery on wrists and hands and the
wearing of nail polish while preparing food.
26.5.1.6. Policies and procedures are available relating to hand-washing procedures and routines.
26.5.1.7. Policies and procedures are available relating to the cleaning of areas and equipment.
26.5.1.8. Policies and procedures are available relating to the disposal of kitchen waste.
26.5.1.9. Policies and procedures are available relating to food preparation procedures and routines.
26.6. Maintenance of food hygiene

26.6.1. Food products and meals are hygienically stored, prepared and served.
Intent of 26.6.1
Foods are stored and prepared in accordance with written protocols, which have been devised by
suitably qualified and experienced personnel, who also control the receipt, storage and preparation of
foods. High-risk foods, which may be contaminated and which may contaminate other foods, are kept
separately. This includes such foods as meat, poultry and fish.
26.6.1 Criteria
26.6.1.1. Foods which are of a potentially high risk, unprepared food and prepared items, are kept separately.
26.6.1.2. Separate cutting boards are kept for raw and cooked food.
26.6.1.3. Food is kept for a minimum amount of time after cooking and before serving.
26.6.1.4. Food waste is put in covered containers and removed without delay from places where food is
prepared.
26.6.1.5. Reheating of chilled food begins no longer than 30 minutes after the food is removed from the chiller.
26.6.1.6. The temperature of the heated food reaches at least 70 degrees centigrade for not less than 2
minutes.
26.6.1.7. Food is served within 15 minutes of reheating.
26.6.1.8. There is a mechanism for ensuring that food handlers report if they or their family suffer from
diarrhoea or vomiting, throat infections, skin rashes, boils or other skin lesions, or eye or ear
infections.
26.6.1.9. Food handlers wear protective clothing which consists of a hat, apron, overall, safety shoes and
gloves where applicable.
26.6.1.10. Persons not normally employed in the food service wear protective clothing while in the area.
26.7. Storage of food stuffs

26.7.1. Food is stored under conditions which ensure security, hygiene and
freshness.
Intent of 26.7.1
The food service manager has a system to ensure, that foods are stored under conditions, which
ensure security, hygiene and freshness. This requires the documentation of standards and monitoring
the conditions under which foods are stored.

26.7.1 Criteria
26.7.1.1. The manager of the food service ensures that secure storage areas are available to food service
personnel.
26.7.1.2. Management ensures that the foods are checked for quality, quantity and temperature on delivery.
26.7.1.3. Management ensures that the storage of food in dry storage, refrigerators and freezers complies with
food hygiene regulations.
26.7.1.4. Foods are stored at acceptable temperatures, utilising thermometers and maintaining temperature
records.
26.7.1.5. Foods are stored separately from non-foods.
26.7.1.6. Foods are stored off the ground on racks or shelving of an impenetrable material.
26.7.1.7. Food types are stored above floor level.
26.7.1.8. Different types of food are kept separately.
26.7.1.9. Stock is rotated.
26.7.1.10. The food stores have ventilation and adequate lighting.
26.7.1.11. Fridges and freezers are capable of being opened from inside through a safety release mechanism.

food service.
Intent of 26.8.1
to ensure, that standards are set for that particular department. This requires co-ordination with the
26.8.1 Criteria
improvement.
26.8.1.4. Complaints relating to food are recorded and acted upon using quality improvement methodology.

26.9.1 Criteria
infection control.


26.10.1 Criteria
safety programme.
26.10.1.5. All staff are trained regarding their role in providing a safe and secure environment.

27.Laundry Service
Overview of Laundry Service

of care throughout the organisation, and to ensure that the laundry service complies with criteria
relating to management, leadership, human resource development, infection control, environmental
safety and quality improvement. This chapter therefore strengthens the standards in previous
chapters, but cannot be used in isolation.

Standards
27.1. Management
27.1.1. The laundry service is managed to ensure the provision of a safe and
effective service.
Intent of 27.1.1
The responsibilities of each staff member in the department are defined in writing. Documents
prepared by each department define its goals, as well as identifying current and planned services.
Lines of communication within each department are documented to ensure clear accountability.
27.1.1 Criteria
27.1.1.1. A person who is suitably trained and experienced manages the service.
27.1.1.2. This individual has appropriate training, education and experience to manage the service.
27.2. Staffing
Intent of 27.2.1
Departmental policies and procedures reflect the knowledge, skills and availability of staff ,required to
27.2.1 Criteria
27.2.1.1. Staff members employed in the service have a written job description which defines their
responsibilities.
27.2.1.2. Staff in the service receive regular in-service training on laundry processes.
organisation.

27.3.1. Policies and procedures guide the management of the service.

Intent of 27.3.1
functions carried out. Departmental policies may be standardised for similar departments or unique to
the organisational leaders. A system needs to be in place to ensure that departmental policies and
27.3.1 Criteria
27.3.1.1. The manager ensures that policies and procedures are available to guide the service.
27.3.1.5. Policies and procedures are available relating to the separation of staff who work in the clean and
soiled areas.
27.3.1.6. Policies and procedures are available relating to the marking of linen to identify ownership.
27.3.1.7. Policies and procedures are available relating to the washing of patients' private clothing.
27.3.1.8. Policies and procedures are available relating to the delivery of clean linen.
27.3.1.9. Policies and procedures are available relating to the obtaining of clean linen in an emergency.
27.3.1.10. Policies and procedures are available relating to the handling of infected linen.
27.3.1.11. Policies and procedures are available relating to the wearing of protective clothing.
27.3.1.12. Policies and procedures are available relating to searching used linen for sharps.
27.3.2. Policies and procedures guide the management of the physical facility.
27.3.2 Criteria
27.3.2.1. Policies and procedures are available relating to the washing time/temperature combinations of
different types of soiled and infected linen, and theatre linen.
27.3.2.2. Policies and procedures are available relating to the maximum capacity loading of the washing
machines (weight of dry fabric to cubic capacity of machine)
27.3.2.3. Policies and procedures are available relating to the maximum capacity loading of dryers (weight of
wet fabric to cubic capacity of machine).
27.3.2.4. Policies and procedures are available relating to the use of chemicals (soaps, sodium chloride
solutions and softeners).
27.3.2.5. Policies and procedures are available relating to the classification of work for processing (colours,
fabrics, degree of soiling).
27.3.2.6. Policies and procedures are available relating to finishing processes and folding of clean linen.
27.4. Physical facilities

27.4.1. The department is designed to allow for safe and effective processing of
laundry.
Intent of 27.4.1
Departmental managers need to work closely with organisational managers to ensure that facilities
and equipment.
27.4.1 Criteria
27.4.1.1. The space in the laundry is adequate to deal with the calculated or estimated dry weight of articles to
be processed and the type of washing equipment.

27.4.1.2. The laundry provides a clear flow of laundry from the soiled to the clean side with no crossover of
these lines.
27.4.1.3. Washing machines are fitted with water level gauges or dip gauges and the quantity of water is
regularly checked.
27.4.1.4. The size and number of washing machines are adequate to meet the number of loads per hour,
considering peak loads.
27.4.1.5. Ironers/laundry presses are adequate to ensure the processing of laundry items without backlog.
27.4.1.6. The machine cage volume is specified by the manufacturer.
27.4.1.7. Loads are regularly weighed.
27.4.1.8. Washing machines are fitted with accurate thermometers.
27.4.1.9. Thermometers are tested 6 weekly and calibrated yearly.

laundry service.
Intent of 27.5.1
27.5.1 Criteria
improvement.
27.5.1.4. Incidents relating to complaints about the laundry are recorded and acted upon using quality
improvement methodology.

27.6.1 Criteria
infection control.

27.7.1 Criteria

safety programme.


28.Housekeeping Service
Overview of Housekeeping Service

of care throughout the organisation, and ensures that the housekeeping service complies with criteria
relating to management, leadership, human resource development, infection control, environmental
safety and quality improvement. This chapter therefore strengthens the standards in previous
chapters, but cannot be used in isolation.

Standards
28.1. Management
28.1.1. The housekeeping service is managed to ensure the provision of a safe and
effective service.
Intent of 28.1.1
Departmental and service managers are primarily responsible for ensuring that the mission of the
28.1.1 Criteria
28.1.1.1. A person who is suitably experienced manages the service.
28.2. Staffing
28.2.1. There are an adequate number of suitably trained staff to provide a safe and
effective service.
Intent of 28.2.1
28.2.1 Criteria
28.2.1.1. Staff members in the unit have a written job description which defines their responsibilities.
28.2.1.2. Staff in the unit receive regular in-service training on housekeeping protocols and methods.
organisation.

28.3.1. Facilities and equipment are adequate to provide a safe and effective
cleaning service.

Intent of 28.3.1
and equipment are adequate. Departmental managers keep organisational managers informed, of
and equipment.
28.3.1 Criteria
28.3.1.1. Secure storage areas and well-maintained equipment are available to housekeeping staff.
28.3.1.2. Chemicals for cleaning are safely stored out of the reach of patients, children and visitors.
28.3.1.3. There is adequate storage place for brooms and mops.
28.3.1.4. Mops and brooms are cleaned and dried before being stored.
28.3.1.5. Cleaning cupboards are adequately ventilated.
28.3.1.6. Soiled linen is placed in bags designated for that purpose.
28.3.1.7. Soiled linen is stored in a secure facility.

28.4.1. Policies and procedures guide the management of the department.
Intent of 28.4.1
the particular department. Housekeeping policies need to be co-ordinated to meet the needs of
departmental leaders, infection control requirements, and the housekeeping staff. They need to be
indexed, available, signed, dated and have the authority of the organisational leaders. A system
needs to be in place to ensure that departmental policies and procedures are known and implemented.
28.4.1 Criteria
28.4.1.1. The manager ensures that policies and procedures are available to guide the department.
28.4.1.6. Policies and procedures are available relating to the supervision of staff.
28.4.1.7. Policies and procedures are available relating to the mixing and use of chemicals for cleaning.
28.4.1.8. Policies and procedures are available relating to the safe storage of cleaning materials.
28.4.1.9. Policies and procedures are available relating to the hygienic storage of mops and brooms.
28.4.1.10. Policies and procedures are available relating to appropriate cleaning methods and materials for
various surfaces.
28.4.1.11. Policies and procedures are available relating to the handling of used and infected linen.
28.4.1.12. Policies and procedures relate to cleaning at times which are least disturbing to the patient care
services.
28.5. Waste disposal

28.5.1. The housekeeping staff work with the infection control committee to ensure
safe waste disposal.
Intent of 28.5.1

Housekeepers play an important role in the removal of clinical waste from departments. Protocols
need to be developed, to guide housekeepers in ensuring the safety of themselves, others and the
environment in the waste removal systems.
28.5.1 Criteria
28.5.1.1. Waste is segregated in accordance with documented controls.
28.5.1.2. Housekeeping staff use colour-coded charts (or other suitable coding), showing the colour of bag and
type of container appropriate to the type of waste generated.
28.5.1.3. Waste is protected from theft, vandalism or scavenging by animals.
28.5.1.4. Waste is collected at appropriate times so that hazards are not caused.

laundry service.
Intent of 28.6.1
28.6.1 Criteria
28.6.1.2. Processes relating to service provision are selected in order of priority for evaluation and
improvement.
28.6.1.4. Incidents relating to complaints about the housekeeping service are recorded and acted upon using
quality improvement methodology.

28.7.1 Criteria
infection control.

28.8.1 Criteria

safety programme.
28.8.1.4. There is a procedure for the handling, storage and disposal of clinical and other waste.


29.Maintenance service
Overview of Maintenance service

The Maintenance service may also be known in some organisations as the Hospital Engineering
department. Whatever it is known as, it concerns itself with the management and maintenance of
hospital plant, machinery and buildings, and non-medical equipment.
Laws, regulations and inspections by national governmental and local authorities determine in large
part, how a facility is designed, used and maintained. All organisations, regardless of their size and
resources, must comply with these requirements, as part of their responsibilities to their patients,
families, staff and visitors. Organisations begin by complying with laws and regulations. Over time,
they become more knowledgeable about the details of the physical facility they occupy. They begin to
proactively gather data and carry out strategies to reduce risks and enhance the patient care
environment.
Buildings, grounds, plant and machinery are provided and maintained, and do not pose hazards to the
occupants. Utility systems (electrical, water, oxygen, ventilation, vacuum and other utility systems) are
maintained, to minimise the risks of operating failures.
Ensuring that buildings, grounds, plant and machinery are provided and maintained requires that staff
be knowledgeable and competent.

Standards

29.1.1. The maintenance service is managed, to ensure the provision of a safe and
effective service.
Intent of 29.1.1
An individual, who is suitably qualified, and with proven competence, is appointed to manage the
service. The accountabilities and responsibilities of this individual are clearly defined.
29.1.1 Criteria
29.1.1.1. An individual, who has appropriate training, education and experience, manages the service.
29.1.1.3. The manager implements health and safety rules, regulations and practices, and is actively involved
in the organisation’s health and safety structures/committees.
29.2. Staffing
Intent of 29.2.1
Management ensures that there are an adequate number of competent staff available to manage
routine and emergency functions, to meet the needs of a safe and effective health service. Staff may
be in the employ of the organisation or contracted out. Where contracted staff are utilised, there need
to be clear contracts, which outline their responsibilities. Staff need to have their roles clearly defined,
and management needs to ensure, that they maintain competence.
29.2.1 Criteria
29.2.1.1. There are an adequate number of suitably trained and experienced staff, to manage the
organisation’s buildings, plant and machinery.
29.2.1.2. In-house maintenance staff have written job descriptions, which define their responsibilities.
29.2.1.3. In-house maintenance staff receive regular in-service training, to enable them to provide a safe and
effective service.
29.2.1.4. The manager has established an orientation and induction programme for the maintenance service
staff.
29.2.1.5. There is a system for the provision of emergency technical backup, 24 hours a day, seven days a
week.
29.2.1.6. Where there are no in-house staff to perform these functions, the services of consultants/service
providers are utilised.
29.2.1.7. Contracts are available, which clearly outline the responsibilities of these service providers.
29.2.1.8. Names of specialist service contractors for buildings, plant and machinery are available, with their
locations, telephone numbers and the responsible persons specified.
29.3. Laws and regulations

29.3.1. The organisation complies with relevant laws, regulations and facility
inspection requirements.

Intent of 29.3.1
The first consideration for any physical facility is the laws, regulations and other requirements related
to that facility. Such requirements may differ, depending on the age of the facility, the location of the
facility and other factors. The organisation's leaders, including governance and senior management,
are responsible for knowing what national and local laws, regulations and other requirements are
applicable to the organisation's facilities, and for implementing the applicable requirements.
29.3.1 Criteria
29.3.1.1. The organisation’s leaders possess documentation, relating to the relevant laws, regulations and
other requirements, applicable to the organisation’s facilities.
29.3.1.2. There is documented evidence to indicate, that the organisation plans to meet applicable laws,
regulations and other requirements.
29.3.1.3. There is evidence that the leaders implement the applicable requirements of these laws, regulations
and other requirements.
29.3.1.4. Inspection reports/certificates of inspection by outside authorities are available, as required by local
laws and regulations.
29.3.1.5. The leaders ensure, that the organisation meets the conditions of facility inspection reports or
citations.
29.3.2. Policies and procedures are developed and implemented, in support of

legislation.
Intent of 29.3.2
Clinical and managerial leaders ensure, that organisational policies and procedures are developed
and implemented. These policies comply with current legislation.
29.3.2 Criteria
29.3.2.1. There are policies and procedures relating to buildings, plant and machinery, which comply with
current legislation.
29.3.2.2. Policies and procedures relate to the upgrading, repair, maintenance and demolition of buildings.
29.3.2.3. Policies and procedures relate to the installation, operation, use, handling, alteration, repair,
maintenance and conveyance of plant, machinery and health and safety equipment.
29.3.2.4. Policies and procedures relate to reporting defects during normal working hours and outside normal
working hours.
29.3.2.5. Policies and procedures relate to the storage, testing and safety of gas supplies.
29.4. Upgrading and replacement

29.4.1. The organisation provides planned maintenance and replacement processes,
to ensure the safety of facilities, plant and machinery.
Intent of 29.4.1
Prevention and planning are essential to creating a safe and supportive patient care facility. The
organisation's leaders, including governance and senior management, are responsible for planning
and budgeting for the necessary upgrading or replacement, as identified by monitoring data or
applicable requirements, and for showing progress made in meeting those plans.
Improvements are made when necessary, such as enhancing electrical services to areas with new
equipment.
Monitoring essential systems helps the organisation to prevent problems, and provides the information
necessary to make decisions on system improvements, and to plan for the upgrading or replacement
of utility systems. Monitoring data are documented.

The organisational leaders use available resources well in providing a safe, effective and efficient
facility.
29.4.1 Criteria
29.4.1.1. There is a documented maintenance management programme in place, which addresses the
maintenance and safety requirements of the buildings, plant and machinery.
29.4.1.2. The organisation plans for the upgrading of buildings, and the replacement of plant and machinery,
needed for the continued operation of a safe and effective facility.
29.4.1.3. The organisation budgets for the implementation of upgrading and replacement plans and the
ongoing maintenance programme.
29.5. Inspections and testing

29.5.1. The organisation plans and implements safety inspections and testing of
facilities, plant and machinery.
Intent of 29.5.1
Facilities may be inspected by outside bodies, eg licensing bodies, local authorities, building
authorities, or local fire departments.
When the organisation has been cited for not meeting requirements, the leaders take the responsibility
for meeting those requirements in the prescribed time frame.
The organisation also plans for regular in-house inspection of facilities, and testing of plant and
machinery to avoid hazards. Plant and machinery are inspected according to the specifications of the
manufacturers, eg air-conditioning plants, generators, or industrial washing machines. In some cases,
the staff of the organisation may carry out the testing, or the manufacturer's technicians may carry out
these tasks. Whatever the system in use, the organisation has a documented plan for the testing of
plant and machinery. During testing, attention is paid to the critical components of systems (eg
switches, relays).
The effective and efficient operation of utility and other key systems in the organisation are essential
for patient, family, staff and visitor safety and for meeting patient care needs. Ventilation in areas such
as theatres, kitchens, sterilising departments and pharmacies needs to be included in the maintenance
programme.
Emergency and back-up power sources are tested under circumstances, which simulate actual load
requirements and according to the manufacturer's instructions.
29.5.1 Criteria
29.5.1.1. The organisation holds regular, documented, current, and accurate inspections of its physical facility,
plant and machinery.
29.5.1.2. The inspection includes a full property appraisal, i.e. physical condition, utilisation, functional
suitability and building requirements.
29.5.1.3. The inspection highlights any requirement for remedial action, with regard to any situations, which
could have an impact on health and safety issues.
29.5.1.4. Site and floor plans depict the locations and layout of the main services (viz. water, sanitation,
electricity supply).
29.5.1.5. Air-conditioning for the theatres is installed, tested and maintained, according to current national
standards.
29.5.1.6. Ventilation in operating theatres, kitchens, pharmacies, sterilising departments, laundries and other
areas, where constant temperatures need to be maintained is identified, monitored, and, where
necessary, improved.
29.5.1.7. Emergency generators are tested every six weeks on full load for at least one hour, or according to
the specifications of the manufacturer.

29.6. Emergency preparedness

29.6.1. The organisation has a process, which is tested on a regular basis, to protect
facility occupants in the event of water or electrical system disruption, contamination
or failure.
Intent of 29.6.1
The organisation needs to protect patients and staff in emergencies, such as system failure,
interruption or contamination.
To prepare for such emergencies, the organisation identifies the equipment, systems and locations
that pose the highest risk to patients and staff. For example it:
• Identifies, where there is a need for illumination, refrigeration, life-support, and clean water for
cleaning and sterilisation supplies;
• assesses and minimises the risks of utility system failures in these areas;
• tests the availability and reliability of emergency sources of power and water; and
• documents the results of tests.
An uninterrupted source of clean water is essential to meet patient care needs, both routine and
urgent, 24 hours a day. Regular and alternate sources can be used.
Water quality can change suddenly due to many causes, some of which can be outside the
organisation, such as a break in the supply line to the organisation, or contamination of the city's water
source. Water quality is also a critical factor in clinical care processes, such as chronic renal dialysis.
Thus, the organisation establishes a process to regularly monitor water quality, including the regular
biological testing of water, used in chronic dialysis. The frequency of monitoring is based, in part, on
previous experience with water quality problems. The monitoring can be carried out by individuals
designated by the organisation, such as staff from the clinical laboratory, or by public health or water
control authorities outside the organisation.
An uninterrupted source of electricity is essential to meet patient care needs, both routine and urgent,
24 hours a day. Regular and alternate sources can be used.
Critical points to be lighted by emergency power are identified and listed. These include:
• operating theatres and recovery rooms;
• delivery rooms' lights and sockets;
• strategic lights and sockets in ward corridors;
• critical care wards;
• the neonatal nursery; and
• casualty and trauma areas.
Emergency electricity supplies:
• each bed/cot/crib is serviced by at least two electricity socket outlets;
• each patient care area is provided with a socket outlet, which is connected to the emergency
power supply, provided that at least one emergency supply socket is available per 3 beds;
• all emergency supply socket outlets are appropriately demarcated.
Records of all checks are available.
Monitoring data are collected and documented for the medical utility management programme and
monitoring data are used for the purposes of planning and improvement.
29.6.1 Criteria

29.6.1.1. Electrical power is available 24 hours a day, seven days a week, from regular or emergency sources.
29.6.1.2. Alternative sources of power are available to cater for emergency situations.
29.6.1.3. The areas and services at greatest risk when power fails have been identified and there are
documented contingency plans in place, to cover such events.
29.6.1.4. The organisation ensures, that relevant personnel are trained in the performance of all operations
pertaining to the provision of emergency power, and that regular, documented training exercises are
held in this regard.
29.6.1.5. Where an uninterruptible power supply (UPS) is installed, it is regularly serviced and tested,
according to the manufacturer’s specifications, with all such tests and maintenance procedures being
fully documented.
29.6.1.6. The battery backup system (battery operated power supply) or UPS for the theatre operating lamp/s
is regularly tested, with such tests being fully documented.
29.6.1.7. Critical points are identified, listed, and provided with emergency power.
29.6.1.8. Those electrical sockets attached to the emergency supply are demarcated.
29.6.1.9. Potable water is available 24 hours a day, seven days a week, from regular or emergency sources.
29.6.1.10. Alternative sources of water are available in the event of failure or contamination of the normal
supply.
29.6.1.11. The areas and services at greatest risk when the water supply is contaminated or interrupted have
been identified and there are documented contingency plans in place to cover such events.
29.6.1.12. The organisation ensures that relevant personnel are trained in the performance of all operations
pertaining to the provision of alternate/emergency potable water supplies, and that regular,
documented training exercises are held in this regard.
29.6.1.13. Water used in chronic renal dialysis is tested on a regular basis and the tests are documented.

maintenance service.
Intent of 29.7.1
and leaders to ensure, that standards are set for that particular department, as part of the
organisation's quality improvement plan. This requires co-ordination with the organisation's steering
committee. Departmental managers use available data and information to identify priority areas for
quality monitoring and improvement. Results of quality improvement monitoring are used to improve
the management of the service.
29.7.1 Criteria
29.7.1.2. Processes related to the maintenance service are selected in order of priority for evaluation of and
improvement in the service provided.
29.7.1.5. Results of quality improvement monitoring are used to improve competence.

29.8.1 Criteria
29.8.1.1. The health and safety representative for the service supervises the implementation of the health and
safety programme.

29.8.1.2. There is a programme for the inspection of patient buildings and a plan to reduce fire risks, for the
protection of patients, staff and visitors.
29.8.1.5. There is documented evidence that staff involved in the handling of clinical and/or hazardous waste
are fully aware of potential hazards, such as needle sticks and other sources of infection or injury.
visitors.


30.Resuscitation Service
Overview of Resuscitation Service

In any healthcare setting it is essential that all staff are prepared to resuscitate patients in a medical
emergency. Resuscitation calls for an integrated, multidisciplinary approach, and the co-ordination of
skills of these disciplines.
The first step in developing a resuscitation programme is the development of protocols, relating to the
levels of resuscitation to be provided, who should provide resuscitation and at what level, the skills,
training and competence of staff required, and the availability of equipment.
To enable effective resuscitation to be provided, equipment must be readily available, checked and
functional. The medical equipment manager is, therefore, an essential member of the team.

Standards
30.1. Resuscitation committee

30.1.1. A resuscitation committee co-ordinates the management of resuscitation
equipment and procedures.
Intent of 30.1.1
Resuscitation equipment and procedures need to be uniform throughout the organisation. This
requires:
• co-ordination among those who provide and maintain the equipment;
• training of staff to use the equipment;
• ensuring the availability of the required equipment;
• maintaining and monitoring equipment; and
• ensuring that required drugs are available.
A competent individual who has the necessary knowledge and expertise with regard to resuscitation
and the equipment required provides this co-ordination. Deficiencies in the system regarding
equipment, its use and the knowledge and skills required by those who carry out resuscitation are
identified, documented and acted upon. Each organisation identifies those members of staff to be
trained in cardiac life-support, and the level of training (basic or advanced) appropriate to their role in
the organisation.
30.1.1 Criteria
30.1.1.1. The organisation identifies a resuscitation committee to advise on resuscitation equipment and
procedures.
30.1.1.2. Each committee member's responsibility for resuscitation is documented in a written job description.
30.1.1.3. A suitably qualified and experienced health professional is appointed as the resuscitation co-
ordinator.
30.1.1.4. The medical equipment co-ordinator is on the committee.
30.1.1.5. A person designated to do so provides information, instruction and training on resuscitation to the
staff of the organisation.
30.1.1.6. The committee checks and documents that systems for the provision of emergency power are
regularly checked.
30.1.1.7. The committee checks and documents that systems for the supply of gases and vacuum are regularly
checked.
30.1.1.8. A member of the resuscitation committee visits (at least monthly) all those departments where
resuscitation equipment is used to monitor all aspects relating to resuscitation and equipment.
30.1.1.9. Records of these visits are kept, with reports on problems experienced, advice given, and any
remedial action taken.
30.1.1.10. There is evidence that these reports are acted upon by hospital management.
30.1.1.11. Policies and procedures relate to the acquisition, use, maintenance and checking of resuscitation
equipment.
30.2. Equipment and drugs

30.2.1. Essential resuscitation equipment and drugs are available for each patient
care area.
Intent of 30.2.1
The resuscitation committee ensures, that the correct equipment is available for resuscitation. This
requires agreeing to and listing those items of equipment deemed to be necessary for resuscitation.
Members of the committee, ensure that regular equipment checks are carried out.

Individuals in patient care areas are responsible for the checking of resuscitation equipment daily, or
after each use, whichever comes first. Records of these tests are maintained.
The medical equipment committee ensures, that resuscitation equipment is accessible in all patient
care areas within one minute.
Resuscitation equipment includes at least:
• A defibrillator with adult and infant paddles
• An ECG monitor
• A CPR board
• Suction apparatus
• An Ambu bag or equivalent
• Oral airways
• Tracheotomy sets, where there is no theatre.
30.2.1 Criteria
30.2.1.1. The organisation has an updated list of equipment required for resuscitation in each area.
30.2.1.2. The committee ensures that resuscitation equipment is readily accessible to every patient care area
in the organisation.
30.2.1.3. The committee checks and documents that resuscitation equipment and drugs are checked daily, or
immediately after use (whichever is the sooner), by persons identified to be responsible for this.
30.2.1.4. The committee documents that records of these checks are made available to them by the persons
responsible.
30.3. Education and training

30.3.1. Relevant staff are suitably trained and educated to provide resuscitation and
competencies are regularly measured.
Intent of 30.3.1
It is the responsibility of the management to ensure that training and education needs for resuscitation
are identified, that appropriate training and education are provided, and that staff show proof of
competence.
30.3.1 Criteria
30.3.1.1. The resuscitation committee develops a continuing education strategy to ensure that all staff in the
organisation keep up to date with matters relating to resuscitation.
30.3.1.2. Information, instruction and training on resuscitation are provided to the staff of the hospital by a
person designated to do so.
30.3.1.3. There is evidence that all members of the resuscitation committee, as well as relevant staff, attend
courses and seminars on resuscitation, and that records of attendance are kept.
30.3.1.4. New employees are provided with resuscitation training within one month of appointment.
30.3.1.5. There is evidence that all staff are updated at least annually on resuscitation matters.
30.3.1.6. Dated records are kept of attendance at in-service training programmes.
30.3.1.7. There is a mechanism whereby staff show proficiency in resuscitation techniques.


resuscitation service.
Intent of 30.4.1
and leaders to ensure that standards are set for that particular department, as part of the
quality monitoring and improvement. Results of quality improvement monitoring are used to improve
the management of the service.
30.4.1 Criteria
30.4.1.2. Processes related to the resuscitation service are selected in order of priority for evaluation and
improvement.

31.Healthcare Technology Management
Overview of Healthcare Technology Management

Medical Equipment Maintenance (MEM) is defined as "An accountable, systematic approach to
ensuring, that cost-effective, safe, efficacious and appropriate equipment is available to meet the
demands of quality patient care" (ECRI,1989).
In this manual, medical equipment management relates to all aspects of medical equipment support,
whereas the maintenance service is responsible for all non-medical equipment.
Healthcare organisations establish appropriate medical equipment management structures and

processes, to ensure improved healthcare delivery. Improved healthcare delivery includes the
provision of safe, affordable, appropriate, effective and sustainable healthcare technology.
The management of equipment needs to be co-ordinated throughout an organisation and a healthcare

technology management advisory committee, therefore, needs to be formed. When new technology is
planned, the committee needs to advise on the available facilities, and on the competence of the staff,
with regard to its sage and maintenance, integration, interfacing, user training and storage and
disposal.
The committee should be co-ordinated by the healthcare technology manager or another appropriate
person.
The healthcare technology advisory committee needs to co-ordinated with other committees, such as
theatre, infection control, resuscitation, health and safety, and quality improvement.
Medical equipment management includes taking inventory, conducting regular inspections and testing,
and preventive maintenance. The effectiveness of medical equipment management is dependent on
the knowledge and skills of those professionals qualified to provide the equipment management
service, and also of those who use the equipment.The medical equipment maintenance manager
implements programmes for training and education.

Standards
31.1. Medical equipment support

31.1.1. Adequate human resources are available for the Medical Equipment
Maintenance Services (MEMS) to ensure safety and the correct management, usage
and operation of medical equipment.
Intent of 31.1.1
Healthcare organisations have a responsibility to ensure, that appropriate medical equipment is
available and ready for use at all times. Suitably qualified or trained individuals take responsibility for
ensuring the provision, maintenance, checking and servicing of medical equipment. These
responsibilities are defined in writing.
There is an accountable, systematic approach to ensuring, that cost-effective, safe, efficacious and
appropriate medical equipment is available to meet the demands of quality patient care.
The mission and objectives of the organisation, level of technology, and geographic location determine
the scope of medical equipment support, which may include:
§ an in-house medical equipment management and maintenance service; or
§ a medical equipment management and maintenance service at a regional or district level; or
§ the use of outside service providers for equipment maintenance and repairs.
31.1.1 Criteria
31.1.1.1. A medical equipment maintenance manager is identified by the organisation i.e. a clinical engineer,
clinical engineering technician, medical equipment technician, or other suitably trained and/or
experienced person, as permitted by current legislation.
31.1.1.2. The responsibilities of the medical equipment maintenance manager are defined in writing.
31.1.1.3. A multidisciplinary Medical Surgical Instruments and Equipment Committee (MSIEC) is appointed to
represent managers, clinical and technical staff involved in the management and use of medical
equipment.
31.1.1.4. Members of the MSIEC are appointed, in writing, based on their competence in the area of healthcare
technology management.
31.1.1.5. The MSIEC has ready access to a reliable source of expertise relating to healthcare technology.
31.1.1.6. The responsibilities of the MSIEC are documented.
31.1.1.7. Responsibilities include supervision of the healthcare technology life cycle.
31.1.1.8. Responsibilities include liaison with the manufacturers/suppliers/service providers.
31.1.1.9. Responsibilities include external provider cost control.
31.1.1.10. Responsibilities include advising on medical equipment management (MEM) related activities,
including risk management and quality improvement.
31.1.1.11. The MSIEC meets regularly to discuss and advise on issues relating to healthcare technology
management and these meetings are minuted.
31.2. Medical equipment plan

31.2.1. A strategic plan for the management of medical equipment is developed.
Intent of 31.2.1
The MSIEC develops a plan for medical instruments and equipment.
The plan includes analysis of existing structures and resources, planning for the acquisition of new
equipment, and maintenance and servicing of existing equipment. The healthcare technology
manager, in consultation with the users of the equipment, advises on new technologies available.

31.2.1 Criteria
31.2.1.1. A technological strategic plan, linked to the clinical strategic plan, is developed.
31.2.1.2. The plan includes audits of existing technology.
31.2.1.3. The plan includes technology assessment for new and emerging technologies.
31.2.1.4. The plan includes replacement and selection of new technologies, using a well-developed set of
criteria.
31.2.1.5. The plan includes setting priorities for equipment acquisition.
31.2.1.6. The plan includes processes to implement equipment acquisition and to monitor ongoing utilisation.

31.3.1. Policies and procedures are developed to support the strategic plan.
Intent of 31.3.1
The implementation of the strategic plan can only take place if there is adequate documentation of
protocols to provide support and guidance.
Policies and procedures are developed in line with current legislation and include the acquisition,
allocation, utilisation and technical support for MEM.
§ Policies and procedures relating to the acquisition of equipment include technical support
requirements and spares, regulatory compliance (compliance with IEC and other international and/or
local standards where such standards exist), and are applicable for the equipment under
consideration.
§ Policies and procedures for equipment acquisition also consider compatibility with other
equipment, suitability for the stated clinical function(s), life cycle costing/cost of ownership, supplier
evaluation, past experience and accessories.
§ Policies and procedures relating to deployment of equipment include availability and preparation of
facilities, installation and commissioning, safety checks, final acceptance checks, connectivity,
integration, interfacing, user training, and the storage and usage of disposables/consumables with
limited shelf life.
31.3.1 Criteria
31.3.1.1. Policies and procedures relating to medical equipment safety and management comply with current
applicable legislation and standards.
31.3.1.2. Policies and procedures are developed for equipment acquisition.
31.3.1.3. Policies and procedures are developed for the deployment of medical equipment.
31.3.1.4. Operator and/or service manuals are available to operators and technicians.
31.4. Medical equipment management

31.4.1. Medical equipment is managed and maintained throughout the organisation.
Intent of 31.4.1
To ensure that medical equipment is available for use and is functioning properly, the organisation:
• takes an inventory of medical equipment, which includes description, make, manufacturer, model,
serial number, tracing number, date of purchase, purchase price, list of accessories, supplier details
and guarantee expiry dates.
• conducts regular inspections of medical equipment;
• tests medical equipment, as appropriate to its use and requirements; and

• provides preventive maintenance.

Equipment is inspected and tested when new and then on an ongoing basis, as appropriate to the age
and use of the equipment, or based on the manufacturer's instructions. Inspections, testing results
and any maintenance are documented. This helps to ensure the continuity of the maintenance
process and helps when capital planning for replacements, upgrades and other changes is being
undertaken.
31.4.1 Criteria
31.4.1.1. The organisation’s budget incorporates an allocation of funds for medical equipment management.
31.4.1.2. The organisation plans and implements a programme for inspecting, testing and maintaining medical
equipment and documenting the results.
31.4.1.3. There is a comprehensive inventory of all medical equipment, which lists equipment type, make,
model, serial number, location, supplier/service provider and date of purchase.
31.4.1.4. Policies and procedures are in place relating to the planning and provision of technical support,
according to the organisation’s needs, with regard to the maintenance and repair of medical
equipment.
31.4.1.5. A documented system, known to all relevant persons, is in place, which addresses the provision of
technical support in first-line emergency situations involving healthcare technology.
31.4.1.6. Adequate technical support is provided in emergency situations.
31.4.1.7. There is a service history for each piece of equipment, which includes signed and dated job-cards
detailing all procedures carried out, parts fitted etc.
31.4.1.8. Names of specialist service contractors are available, with their locations, telephone numbers, and
the responsible persons specified.
31.4.1.9. Initial commissioning records are available, for all high-risk medical equipment, which include details
of tests performed and training given.
31.4.1.10. Records of service procedures performed on all equipment are provided to the appropriate patient
care managers.
31.4.2. Where there are pipeline installations for medical gas and vacuum, systems
are regularly inspected, maintained and, when appropriate, improved.
Intent of 31.4.2
The organisation plans its needs for oxygen and vacuum supplies, according to the needs of the
patients served.
Policies and procedures are available and followed relating to the storage, testing and safety of gas
supplies.
Gas cylinders are stored in outside facilities, chained in the upright position, and have "no-smoking"
and "no oil" signs.
Emergency oxygen supplies ensure that:
• there is at least one oxygen and one vacuum point for every 2 beds;
• where there is no piped oxygen and vacuum supply, there is at least one mobile oxygen supply
and one vacuum pump per ward, and more depending on the number of beds/cots in the ward;
• all necessary fittings for oxygen and suction are suitable for the ages of the children admitted, and
are working satisfactorily.
Vacuum systems are regularly tested in accordance with the specifications of the suppliers.
31.4.2 Criteria
31.4.2.1. Where there is piped gas, oxygen, nitrous oxide and medical air (where applicable), these are
supplied via a pipeline system, which complies with relevant safety standards.
31.4.2.2. Where there is piped gas, the enclosure, gas bank, pressure regulators, related control/alarm
systems and all outlet points are clean and in good operating condition.
31.4.2.3. Where there is piped gas, the main oxygen supply system is fitted with an alarm, which operates
automatically in the event of low pressure in the gas supplies and is regularly tested, with the results
being documented.

31.4.2.4. Medical gas alarm systems are regularly tested and the tests are documented.
31.4.2.5. Backup supplies of oxygen, nitrous oxide and medical air (where applicable) are available – according
to the organisation’s policy - in the event of a failure in the pipeline system.
31.4.2.6. Gas cylinders are safety-checked on receipt, weekly, and before leaving bulk storage.
31.4.2.7. Gas cylinders are stored in accordance with local safety standards.
31.4.2.8. Where there is a piped vacuum system, it is externally ventilated and able to provide sufficient suction
to all piped vacuum points in the hospital.
31.4.2.9. Where there is a piped vacuum, there are backup facilities (i.e. manually or battery-operated units)
are provided, in accordance with the organisation’s policy, in the event of a total power failure (i.e.
both primary and emergency supplies).
31.4.2.10. Records of tests of gas and vacuum supplies are available.
31.4.3. Where there are no pipeline installations, medical gas and vacuum facilities
are regularly inspected, maintained and, when appropriate, improved.
31.4.3 Criteria
31.4.3.1. Where there is no piped gas, supplies of oxygen, nitrous oxide and medical air (where applicable) are
provided, according to the organisation’s policy, by cylinders and associated pressure regulators,
which comply with relevant safety standards.
31.4.3.2. Where there is no piped gas, all pressure regulators, flow meters and other metering devices are
clean and in good operating condition.
31.4.3.3. Medical gas regulators are regularly tested and the tests are documented.
31.4.3.4. Gas cylinders are checked on receipt, weekly, and before leaving bulk storage.
31.4.3.5. Gas cylinders are stored in accordance with local safety regulations.
31.4.3.6. Where there is no piped vacuum, backup facilities are available (i.e. manually or battery operated
units), in accordance with the organisation’s policy, in the event of a total power failure.
31.4.4. Appropriate human, infrastructural and technical resources are available for
the medical equipment management department to ensure adequate medical
equipment support.
31.4.4 Criteria
31.4.4.1. The organisation has direct access to adequate (i.e. according to the needs of the organisation),
suitably qualified/trained technical support from this source.
31.4.4.2. Inspection/preventive maintenance (IPM) procedures are carried out according to the service
requirements specified by the relevant equipment’s manufacturers.
31.4.4.3. The medical equipment management department has access to all specialised test equipment and
consumables as specified by the manufacturer of the medical equipment for which it is responsible.
31.5. Staff training

31.5.1. There are systems in place to ensure that all users of medical equipment and
devices are competent in the use thereof.
Intent of 31.5.1
The complexity of MEM requires that all users and operators of medical equipment receive training
and education in its operation. Also those ancillary staff, who impact on technology utilisation and/or
availability (e.g. stores department staff), should receive basic appropriate training, which may include
identification of medical equipment, devices, accessories and common spares, etc.
All staff need to be trained in risk management, infection control and resuscitation. Those persons
involved in MEM participate in the organisation's in-service training programme on these issues, and
also ensure, that education and training are provided, which is specific for their own department.
The organisation has a responsibility to facilitate professional development and competence of its staff

in matters relating to MEM, and staff have a responsibility to maintain their own competence and
current knowledge.
31.5.1 Criteria
31.5.1.1. There is a system for ensuring that users and operators possess the knowledge and skills necessary
for the safe and correct usage of equipment, devices and instruments.
31.5.1.2. Ongoing training is provided for users and operators of complex and/or critical life-support equipment,
with a record of all such training given and successfully completed.
31.5.1.3. All users and operators of medical equipment are provided with training in basic infection control and
decontamination procedures.
31.5.1.4. A record of staff training is kept.
31.5.2. Sufficient resources are allocated to ensure adequate training and education
for medical equipment management (MEM) personnel.
31.5.2 Criteria
31.5.2.1. MEM staff are provided with appropriate training, in respect of all medical equipment, devices and
instruments, which they are expected to maintain and/or repair.
31.5.2.2. MEM staff are encouraged and assisted by management to attend seminars, congresses,
conferences and training sessions, which could improve their knowledge of and proficiency in medical
technology matters.
31.5.2.3. MEM staff are provided with access to appropriate support documentation, such as equipment
standards and other regulatory documentation.
31.5.2.4. MEM staff are provided with training in basic infection control and decontamination procedures.
31.6. Equipment safety

31.6.1. Systems are in place to ensure safe working conditions and the safety of
equipment in MEM workshops.
Intent of 31.6.1
Staff ensure, that equipment is tested and maintained in a safe working environment. Risk
management includes identifying hazards to both staff and patients, and reducing the risk of hazards,
which may cause injury or death. Those working with equipment are responsible for ensuring that the
environment is safe.
31.6.1 Criteria
31.6.1.1. Staff responsible for MEM implement risk management, in terms of the organisation’s health and
safety programme.
31.6.1.2. Training in basic electrical safety is provided to all staff involved in the use of electrically operated
equipment.
31.6.1.3. There is an adequate scavenging system for the removal of nitrous oxide and volatile anaesthetic
agents in the medical equipment workshop.
31.6.1.4. Where anaesthetic vaporisers are tested/serviced, a suitable fume extraction chamber is provided.
31.6.1.5. Where extensive soldering work is undertaken, soldering stations are provided with a suitable fume
extraction system.
31.6.1.6. Where volatile cleaning agents are used, an appropriate fume extraction chamber is provided for the
safe dispersal of hazardous vapours, e.g. ether.
31.6.1.7. A system is in place for the safe disposal of hazardous substances.
31.6.1.8. The medical equipment workshop has adequate 15 amp. electrical power outlets. At least two of
these are fitted with filters, to deliver a clean interference-free supply.
31.6.1.9. The medical equipment workshop is fitted with air-conditioning capable of maintaining a year-round
constant temperature of 21 degrees C.
31.6.1.10. A system exists for obtaining information on medical device hazard alerts or safety bulletins and
acting upon these when applicable.


MEM service.
Intent of 31.7.1
The organisational management is committed to improving the quality of care provided through
improved management of technology.
Establishment and support of a quality improvement committee, focusing on healthcare technology
issues, and representing key groups in the organisation is essential to providing a quality service.
Results of quality improvement monitoring are used to improve the management of the service, eg
frequency and duration of use, user acceptance, user training and training evaluation, equipment
downtime, number and type of faults, failures, incidents and cost-effectiveness.
31.7.1 Criteria
31.7.1.2. Processes related to the healthcare technology management service are selected in order of priority
for evaluation of and improvement in the service provided.
31.7.1.3. Monitoring data are collected and documented for the medical equipment management programme.
31.7.1.4. Monitoring data include equipment failures and user errors.
31.7.1.7. Equipment utilisation indices are developed for both medical and specialised test equipment (where
applicable).
31.7.1.8. Repair turn-around times and cost analysis of in-house and/or external technical support programmes
are monitored.
31.7.1.9. A system exists for the reporting and processing of in-house equipment-related incidents.


PROFESSIONAL SERVICES
32.Physiotherapy Service
Overview of Physiotherapy Service

of care throughout the organisation, and needs to comply with criteria relating to management,
leadership, human resource development, infection control, environmental safety and quality
improvement. This chapter, therefore, strengthens the standards in previous chapters, but cannot be
used in isolation.

Standards

32.1.1. The physiotherapy service is managed to ensure the provision of a safe and
effective service.
Intent of 32.1.1
organisation is met through the provision of management and leadership at departmental level. Good
32.1.1 Criteria
32.1.1.1. A physiotherapist who is suitably qualified and experienced manages the service.
32.2. Staffing
Intent of 32.2.1
assess and meet patient care needs. The appointment and reappointment of professional staff are
based on proof of competence. Competence is maintained in various ways – through the attendance
of professional society workshops, keeping updated through current available literature, attending
symposia, and through peer review. Proof of competence may be shown through systems of
credentialing, privileging and peer review.
32.2.1 Criteria
32.2.1.1. Physiotherapy staff have written job descriptions which define their responsibilities.
32.2.1.2. Physiotherapy staff receive regular in-service training to enable them to provide a safe and effective
service.
32.2.1.3. Physiotherapists make use of opportunities to participate in advanced education, research and other
experiences.
32.2.1.4. Where credentialling is required by the professional body, physiotherapists show proof of credentials.
32.2.1.5. Physiotherapists practise within the scope of practice of the profession and the privileging
requirements of the organisation.
32.2.1.6. There is a system of peer review amongst physiotherapists within the organisation.

32.3.1. The service has adequate facilities and equipment to meet the treatment
needs of the population served.
Intent of 32.3.1
Departmental managers need to work closely with organisational managers to ensure, that facilities
and equipment.
32.3.1 Criteria
32.3.1.1. There is adequate space for physiotherapists to treat patients effectively.
32.3.1.2. There is adequate space for the storage of equipment and materials.
32.3.1.3. Privacy is ensured through private cubicles, curtains or screens.
32.3.1.4. There is adequate and relevant equipment and materials to provide an effective service.

32.4.1. Policies and procedures guide management and patient care in the
department.
Intent of 32.4.1
the organisation's leaders. A system needs to be in place to ensure that departmental policies and
procedures are known and implemented. Clinical policies and procedures guide professional staff in
the uniform care of patients.
32.4.1 Criteria
physiotherapy service.
32.5. Patient assessment

32.5.1. All patients treated by physiotherapists have their healthcare needs identified
through an established assessment process.
Intent of 32.5.1
The assessment process needs to be planned and implemented, to provide uniform assessments for
all patients. Guidelines aid the implementation of uniform assessment processes. These are often
available from the professional society. The assessment process will be modified to meet the needs of
each patient.
32.5.1 Criteria
32.5.1.1. There is a documented system for the assessment of patients.

32.5.1.2. The process includes appropriate time frames for performing assessments.
32.5.1.3. Assessments are completed within the time frames established by the physiotherapist service.
32.5.1.4. Guidelines are available to ensure appropriate assessment of the needs of particular patients.
32.5.1.5. The findings of assessments performed outside the organisation are verified at first assessment.
32.5.1.7. The initial assessment results in an understanding of the care the patient is seeking, an
understanding of any previous care, an initial diagnosis, and selection of the best setting for the care.
32.5.1.8. Assessment findings are documented in the patient's record within the specified time frame, and are
readily available to those responsible for the patient's care.
32.5.1.9. Patient assessment data and information are analysed and integrated.
32.5.2. All patients are reassessed at appropriate intervals to determine their

response to care and treatment, and to plan for continued treatment or discharge.
Intent of 32.5.2
Regular reassessments of patients ensure, that the continuing care plan is suited to the needs of
patients, and are essential to justify the treatment plan and ongoing care.
32.5.2 Criteria
32.5.2.1. Patients are reassessed to determine their response to care and treatment.
32.5.2.2. Patients are reassessed to plan for continued care and treatment.
32.5.2.3. Patients are reassessed at intervals appropriate to their condition, plan of care, individual needs or
according to organisation policies and procedures.
32.5.2.4. Reassessments are documented in the patient's record.
32.6. Patient care

record.
Intent of 32.6.1
Professional staff have a responsibility to ensure, that they are employing up-to-date methods for
diagnosis and management, which are broadly consistent with those of other practitioners of the same
profession. Adequate medical records are essential for maintaining continuity of care, professional
development and medico-legal protection.
32.6.1 Criteria
32.6.1.1. Clinical practice guidelines, when available and relevant to the patients, are used to guide patient
care processes.
32.6.1.2. Physiotherapists set criteria to select clinical practice guidelines.
32.6.1.3. Physiotherapists adapt guidelines as appropriate for the patients served by the organisation and the
resources available within the service.
32.6.1.4. Physiotherapists review guidelines on a regular basis after implementation.
32.6.1.9. The physiotherapist ensures that there is a process to share information with other care providers.

32.7.1. Education supports patient and family participation in care decisions and care
processes.

Intent of 32.7.1
The service provides education and information to patients on how they can prevent illness and
improve their own health. The service has a range of health promotion information materials and
resources, specific to the particular patient population. Health information provided is recorded, to
ensure follow-up, and to reduce medico-legal risks.
32.7.1 Criteria
32.7.1.1. When appropriate, patients and families are educated about the use of rehabilitation techniques.
32.7.1.2. When appropriate, patients and families are educated about the use of equipment.
32.7.1.3. Education provided includes continuing health promotion and disease prevention.
32.7.1.4. Education provided is noted in the patient's record.

physiotherapy service.
Intent of 32.8.1
quality monitoring and improvement. Clinical indicators focus on high-risk or problem-prone conditions
or procedures, and measure both the process and outcome of patient care. Results of quality
improvement monitoring are used to improve professional practice.
32.8.1 Criteria
32.8.1.1. Indicators of performance are identified to evaluate the quality of care.
32.8.1.2. Processes for quality improvement are selected in order of priority for evaluation and improvement.
32.8.1.3. Quality improvement processes take into account high volume of patients, patients who are at high
risk, and those whose care is provided at high cost.
32.8.1.4. Processes evaluated include patient care and patient care outcomes.
32.8.1.5. There is a relevant monitoring system for care.
32.8.1.7. Results of quality improvement monitoring are used to improve clinical practice.
32.8.1.8. Staff use the results of clinical audits and documentation audits to continuously improve care.

32.9.1 Criteria
specimens.

infection control.

32.10.1 Criteria
safety programme.

33.Occupational Therapy Service
Overview of Occupational Therapy Service

used in isolation.

Standards

33.1.1. The occupational therapy service is managed to ensure the provision of a
safe and effective service.
Intent of 33.1.1
33.1.1 Criteria
33.1.1.1. An occupational therapist who is suitably qualified and experienced manages the service.
33.2. Staffing
Intent of 33.2.1
assess and meet patient care needs. The appointment and reappointment of professional staff is
33.2.1 Criteria
33.2.1.1. Occupational therapy staff have a written job description which defines their responsibilities.
33.2.1.2. Occupational therapy staff receive regular in-service training to enable them to provide a safe and
effective service.
33.2.1.3. Occupational therapists make use of opportunities to participate in advanced education, research and
other experiences.
33.2.1.4. Where credentialling is required by the professional body, occupational therapists show proof of
credentials.
33.2.1.5. Occupational therapists practise within the scope of practice of the profession and the privileging
33.2.1.6. There is a system of peer review amongst occupational therapists within the organisation.


Intent of 33.3.1
and equipment.
33.3.1 Criteria
33.3.1.1. There is adequate space for occupational therapists to treat patients effectively.

department.
Intent of 33.4.1
the organisation leaders. A system needs to be in place to ensure that departmental policies and
33.4.1 Criteria
occupational therapy service.

33.5.1. All patients treated by occupational therapists have their healthcare needs
Intent of 33.5.1
each patient.

33.5.1 Criteria
33.5.1.3. Assessments are completed within the time frames established by the occupational therapist service.
33.5.1.8. Assessment findings are documented in the patient record within the specified time frame, and are

Intent of 33.5.2
Regular reassessments of patients ensure that the continuing care plan is suited to the needs of
33.5.2 Criteria
33.6. Patient care

record.
Intent of 33.6.1
Professional staff have a responsibility to ensure that they employ up-to-date methods for diagnosis
and management, which are broadly consistent with those of other practitioners of the same
33.6.1 Criteria
33.6.1.1. Clinical practice guidelines, when available and relevant to the patients and services of the
organisation, are used to guide patient care processes.
33.6.1.2. Occupational therapists set criteria to select clinical practice guidelines.
33.6.1.3. Occupational therapists adapt guidelines as appropriate to the patients served by the organisation
and the resources available within the service.
33.6.1.4. Occupational therapists review guidelines on a regular basis after implementation.
33.6.1.9. The occupational therapist ensures that there is a process to share information with other care
providers.


processes.
Intent of 33.7.1
ensure follow-up and to reduce medico-legal risks.
33.7.1 Criteria

occupational therapy service.
Intent of 33.8.1
managers and leaders to ensure that standards are set for that particular department, as part of the
33.8.1 Criteria

33.9.1 Criteria
safety programme.


34.Dietetic Service
Overview of Dietetic Service

of care throughout the organisation, and needs to comply with criteria, relating to management,
used in isolation.

Standards

34.1.1. The dietetic service is managed to ensure the provision of a safe and
effective service.
Intent of 34.1.1
34.1.1 Criteria
34.1.1.1. A dietician who is suitably qualified and experienced manages the service.
34.2. Staffing
Intent of 34.2.1
34.2.1 Criteria
34.2.1.1. Dietetic staff have a written job description which defines their responsibilities.
34.2.1.2. Dietetic staff receive regular in-service training to enable them to provide a safe and effective service.
34.2.1.3. Dieticians make use of opportunities to participate in advanced education, research and other
experiences.
34.2.1.4. Where credentialling is required by the professional body, dieticians show proof of credentials.
34.2.1.5. Dieticians practise within the scope of practice of the profession and the privileging requirements of
the organisation.
34.2.1.6. There is a system of peer review amongst dieticians within the organisation.


Intent of 34.3.1
and equipment.
34.3.1 Criteria
34.3.1.1. There is adequate space for dieticians to treat patients effectively.

department.
Intent of 34.4.1
34.4.1 Criteria
34.4.1.1. Policies and procedures are available to guide staff in management and clinical aspects of the dietetic
service.

34.5.1. All patients treated by dieticians have their healthcare needs identified
through an established assessment process.
Intent of 34.5.1
each patient.
34.5.1 Criteria


34.5.1.3. Assessments are completed within the time frames established by the dietetic service.
34.5.1.8. Assessment findings are documented in the patient record within the specified time frame, and are

Intent of 34.5.2
Regular reassessments of patients ensure that the continuing care plan is suited to the needs of
34.5.2 Criteria
34.6. Patient care

record.
Intent of 34.6.1
Professional staff have a responsibility to ensure that they employ up-to-date methods for diagnosis
and management, which are broadly consistent with those of other practitioners of the same
34.6.1 Criteria
34.6.1.2. Dieticians set criteria to select clinical practice guidelines.
34.6.1.3. Dieticians adapt guidelines as appropriate to the patients served by the organisation and the
34.6.1.4. Dieticians review guidelines on a regular basis after implementation.
34.6.1.9. The dietician ensures that there is a process to share information with other care providers.

processes.
Intent of 34.7.1
34.7.1 Criteria

dietetic service.
Intent of 34.8.1
managers and leaders to ensure that standards are set for that particular department, as part of the
34.8.1 Criteria

34.9.1 Criteria
safety programme.


35.Speech Therapy Service
Overview of Speech Therapy Service

used in isolation.

Standards

35.1.1. The speech therapy service is managed to ensure the provision of a safe and
effective service.
Intent of 35.1.1
35.1.1 Criteria
35.1.1.1. A speech therapist who is suitably qualified and experienced manages the service.
35.2. Staffing
Intent of 35.2.1
35.2.1 Criteria
35.2.1.1. Speech therapy staff have a written job description which defines their responsibilities.
35.2.1.2. Speech therapy staff receive regular in-service training to enable them to provide a safe and effective
service.
35.2.1.3. Speech therapists make use of opportunities to participate in advanced education, research and other
experiences.
35.2.1.4. Where credentialling is required by the professional body, speech therapists show proof of
credentials.
35.2.1.5. Speech therapists practise within the scope of practice of the profession and the privileging
35.2.1.6. There is a system of peer review amongst speech therapists within the organisation.


Intent of 35.3.1
Departmental managers need to work closely with organisation managers to ensure that facilities and
equipment are adequate. Departmental managers keep organisational managers informed of facilities,
which are inadequate, additional equipment requirements, and the current state of facilities and
equipment.
35.3.1 Criteria
35.3.1.1. There is adequate space for speech therapists to treat patients effectively.

department.
Intent of 35.4.1
35.4.1 Criteria
35.4.1.1. Policies and procedures are available to guide staff in the management and clinical aspects of the
speech therapy service.

35.5.1. All patients treated by speech therapists have their healthcare needs
Intent of 35.5.1
each patient.

35.5.1 Criteria
35.5.1.3. Assessments are completed within the time frames established by the speech therapist service.

response to care and treatment and to plan for continued treatment or discharge.
Intent of 35.5.2
patients. Such assessments are essential to justify the treatment plan and ongoing care.
35.5.2 Criteria
35.6. Patient care

record.
Intent of 35.6.1
Professional staff have a responsibility to ensure, that they are employing up-to-date methods for
35.6.1 Criteria
35.6.1.2. Speech therapists set criteria to select clinical practice guidelines.
35.6.1.3. Speech therapists adapt guidelines as appropriate for the patients served by the organisation and the
35.6.1.4. Speech therapists review guidelines on a regular basis after implementation.
35.6.1.9. The speech therapist ensures that there is a process to share information with other care providers.


processes.
Intent of 35.7.1
35.7.1 Criteria

speech therapy service.
Intent of 35.8.1
35.8.1 Criteria


36.Clinical Psychology Service
Overview of Clinical Psychology Service

leadership, human resource development, environmental safety and quality improvement. This
chapter, therefore, strengthens the standards in previous chapters, but cannot be used in isolation.

Standards

36.1.1. The clinical psychology service is managed to ensure the provision of a safe
and effective service.
Intent of 36.1.1
36.1.1 Criteria
36.1.1.1. A clinical psychologist who is suitably qualified and experienced manages the service.
36.2. Staffing
Intent of 36.2.1
36.2.1 Criteria
36.2.1.1. Clinical psychology staff have a written job description which defines their responsibilities.
36.2.1.2. Clinical psychology staff receive regular in-service training to enable them to provide a safe and
effective service.
36.2.1.3. Clinical psychologists make use of opportunities to participate in advanced education, research and
other experiences.
36.2.1.4. Where the professional body requires credentialling, clinical psychologists show proof of credentials.
36.2.1.5. Clinical psychologists practise within the scope of practice of the profession and the privileging
36.2.1.6. There is a system of peer review amongst clinical psychologists within the organisation.


Intent of 36.3.1
and equipment.
36.3.1 Criteria
36.3.1.1. There is adequate space for clinical psychologists to treat patients effectively.
36.3.1.3. Privacy is ensured through private consulting rooms.

department.
Intent of 36.4.1
36.4.1 Criteria
36.4.1.1. Policies and procedures are available to guide staff in the management and clinical aspects of the
clinical psychology service.

36.5.1. All patients treated by clinical psychologists have their healthcare needs
Intent of 36.5.1
each patient.
36.5.1 Criteria

36.5.1.3. Assessments are completed within the time frames established by the clinical psychology service.
36.5.2. All patients reassessed at appropriate intervals to determine their response,

to care and treatment and to plan for continued treatment or discharge.
Intent of 36.5.2
patients. Such assessments are essential to justify the treatment plan and ongoing care.
36.5.2 Criteria
36.6. Patient care

record.
Intent of 36.6.1
Professional staff have a responsibility to ensure that they are employing up-to-date methods for
36.6.1 Criteria
36.6.1.2. Clinical psychologists set criteria to select clinical practice guidelines.
36.6.1.3. Clinical psychologists adapt guidelines as appropriate to the patients served by the organisation and
the resources available within the service.
36.6.1.4. Clinical psychologists review guidelines on a regular basis after implementation.
36.6.1.9. The clinical psychologist ensures that there is a process to share information with other care
providers, taking into account the need for confidentiality.

processes.
Intent of 36.7.1
36.7.1 Criteria

clinical psychology service.
Intent of 36.8.1
36.8.1 Criteria


37.Social Work Service
Overview of Social Work Service

used in isolation.

Standards

37.1.1. The social work service is managed to ensure the provision of a safe and
effective service.
Intent of 37.1.1
37.1.1 Criteria
37.1.1.1. A social worker who is suitably qualified and experienced manages the service.
37.2. Staffing
Intent of 37.2.1
37.2.1 Criteria
37.2.1.1. Social work staff have written job descriptions which define their responsibilities.
37.2.1.2. Social work staff receive regular in-service training to enable them to provide a safe and effective
service.
37.2.1.3. Social workers make use of opportunities to participate in advanced education, research and other
experiences.
37.2.1.4. Where credentialling is required by the professional body, social workers show proof of credentials.
37.2.1.5. Social workers practise within the scope of practice of the profession and the privileging requirements
of the organisation.
37.2.1.6. There is a system of peer review amongst social workers within the organisation.


37.3.1. The service has adequate facilities and equipment to meet patients' needs for
privacy during consultation.
Intent of 37.3.1
and equipment.
37.3.1 Criteria
37.3.1.1. There is adequate space for social workers to consult with patients effectively.
37.3.1.2. There is adequate space for administration.
37.3.1.3. Privacy is ensured through separate consulting rooms or soundproof booths.

37.4.1. Policies and procedures guide management and client services in the
department.
Intent of 37.4.1
37.4.1 Criteria
37.4.1.1. Policies and procedures are available to guide staff in management and clinical aspects of the social
work service.

37.5.1. All clients assessed by social workers have their needs identified through an
established assessment process.
Intent of 37.5.1
all clients. Guidelines aid the implementation of uniform assessment processes. These are often
each patient.
37.5.1 Criteria

37.5.1.3. Assessments are completed within the time frames established by the social work service.
37.5.1.6. Any significant changes in the patient's social condition since the report are noted in the patient's
record.
understanding of any previous care, and selection of the best setting for the care.

response to care and treatment and to plan for continued treatment or discharge.
Intent of 37.5.2
Regular reassessments of patients ensure that the social care plan is suited to the needs of clients.
Such assessments are essential to justify the social interventions implemented.
37.5.2 Criteria
37.5.2.1. Patients are reassessed to determine their response to the social care plan.
37.5.2.2. Patients are reassessed to plan for continued care.
37.5.2.3. Patients are reassessed at intervals appropriate to their social needs, plan of care, individual needs or
37.6. Patient care

record.
Intent of 37.6.1
Social workers have a responsibility to ensure that they are employing up-to-date methods for patient
management, which are broadly consistent with those of other practitioners of the same profession.
Adequate social records are essential for maintaining continuity of care, professional development and
medico-legal protection.
37.6.1 Criteria
37.6.1.1. Social work guidelines, when available and relevant to the patients and services of the organisation,
are used to guide social work processes.
37.6.1.2. Social workers set criteria to select guidelines.
37.6.1.3. Social workers adapt guidelines as appropriate for the patients served by the organisation and the
37.6.1.4. Social workers review guidelines on a regular basis after implementation.
37.6.1.5. The intervention for each patient is planned and noted in the patient's record.
37.6.1.6. The planned intervention is provided and noted in the patient's record.
37.6.1.8. The social worker ensures that there is a process to share information with other care providers.

37.7.1. Education supports patient and family participation in social care decisions
and social care processes.

Intent of 37.7.1
resources specific to the particular patient population. Health information provided is recorded, to
37.7.1 Criteria
37.7.1.1. Patients are educated about social support systems in the community and about their use.

social work service.
Intent of 37.8.1
37.8.1 Criteria
37.8.1.2. Processes related to the social work service are selected in order of priority for evaluation and
improvement.
37.8.1.3. Processes evaluated include social work interventions and outcomes.
37.8.1.6. Results of quality improvement monitoring are used to improve professional practice.


39.Dental Service
Overview of Dental Service

and co-ordination.
Continuity of care
organisation.
providers, must be implemented in and between all services.
Leaders of various settings and services work together, to design and implement the required
processes, and thus ensure co-ordination of care.

Standards

patient's care.
Intent of 39.1.1
39.1.1 Criteria
39.1.1.1. The individuals responsible for the patient’s care are designated.
39.1.1.2. The individuals responsible for the patient’s care are qualified.
39.1.1.3. The individuals responsible for the patient’s care are
identified and made known to the patient and other staff.
39.1.1.4. There is a dental roster to ensure that dental staff are available at all times, either on call or on the
premises.
39.1.1.5. Contactable telephone numbers for routine and emergency calls are made known to dental service
staff through posting at departmental telephones.
39.1.1.6. Specialist consultants are available for referral.
39.1.2. The delivery of services is integrated and co-ordinated among care providers.
Intent of 39.1.2
The co-ordination of patient care depends on the exchange of information between the various
members of the multidisciplinary team. This can be through verbal, written or electronic means
according to appropriate policies determined by the organisation. Clinical leaders should use
appropriate techniques, to better integrate and co-ordinate care for their patients (for example, team-
delivered care, combined care planning forums, integrated patient records, case managers). The
39.1.2 Criteria
39.1.2.2. The patient’s record is available to the care providers to facilitate the exchange of information.
39.1.2.4. Information exchanged includes the patient’s health status.
39.1.2.6. Information exchanged includes the patient’s progress.
39.2. Assessments of patients


Intent of 39.2.1
provided.
39.2.1 Criteria
ongoing care.
assessments.
39.2.1.3. The scope and content of assessment by each discipline are defined.
39.2.1.5. Any significant changes in the patient’s condition since the report are noted in the patient’s record.
unwanted variation.
Intent of 39.2.2
organisational leaders and clinical practitioners before implementation. This ensures that they meet
39.2.2 Criteria
39.2.3. Each patient has an initial assessment, which complies with current policies,
Intent of 39.2.3
initiation of the care process. Patients' social, cultural and family status are important factors, which
can influence their response to illness and care. Families can be of considerable help in these areas of
assessment and in understanding the patient's wishes and preferences. Economic factors are
assessed as part of the social assessment, particularly when the patient and his or her family will be
responsible for the cost of all or a portion of the care.

Functional and nutritional assessments allow for the patient to be referred for specialist care if
necessary.
39.2.3 Criteria
39.2.3.1. Each patient has an initial assessment which meets organisational policy.
39.2.3.2. The initial assessment includes a health history.
39.2.3.3. The initial assessment includes a physical examination.
39.2.3.4. The initial assessment includes functional and nutritional assessments, where the need is identified.
39.2.3.5. The initial assessment includes social, cultural and economic assessments.
39.2.3.9. The initial assessment results in the identification of the patient’s medical and nursing needs.
39.2.3.10. The organisation identifies patients in pain, during the assessment process.
39.2.4. Healthcare professionals, responsible for patient care, collaborate to analyse

Intent of 39.2.4
39.2.4 Criteria
39.2.4.1. Assessment findings are documented in the patient’s record and are readily available to those
responsible for the patient’s care.
patient’s care.
39.3. Patient care

39.3.1. The dental department is equipped and managed, to provide an effective
service.
Intent of 39.3.1


39.3.1 Criteria
39.3.1.1. Patient and staff accommodation in the service are adequate to meet patient care needs.
39.3.1.2. The dental service department has adequate light and ventilation.
39.3.1.3. The dental service ensures the availability and maintenance of equipment, drugs and agents required
for safe dental care.
39.3.1.4. The equipment used is appropriate to the type of dental care provided.
39.3.1.5. Where radiographic equipment is used, this conforms with the Ionising Radiation’s regulations.
39.3.1.6. Appropriate shielding and protective clothing is worn in the presence of biohazards or radiographic
equipment which conforms with the Ionising radiation’s regulations.
39.3.1.7. Dental equipment is maintained, in accordance with the organisation’s policies.
39.3.1.8. Resuscitation equipment is available, in accordance with the policies of the organisation.
39.3.1.9. Electricity and water are available, in accordance with the policies of the organisation.
possible time.
Intent of 39.3.2
39.3.2 Criteria
39.3.2.2. Patients who are waiting, are advised of any delays that may be experienced in receiving attention.
39.3.2.3. There is a system for accommodating urgent cases, without disrupting the appointment times.
39.3.2.5. Waiting times are monitored as part of the organisation’s quality management and improvement
programme.
39.3.3. The care provided to each patient is planned and written in the patient’s
record.
Intent of 39.3.3
Collaborative care and treatment team meetings, or similar patient discussions, are recorded.
Individuals, qualified to do so, order diagnostic and other procedures. These orders must be easily
accessible, if they are to be acted on in a timely manner. Locating orders on a common sheet, or in a

39.3.3 Criteria
39.3.3.1. The care for each patient is planned and noted in the patient’s record.
39.3.3.2. The planned care is provided and noted in the patient’s record.
39.3.3.3. Any patient care meetings or other discussions are noted in the patient’s record.
39.3.3.4. All procedures and diagnostic tests, ordered and performed, are written into the patient’s record.
39.3.3.7. The results of procedures and diagnostic tests performed are available in the patient’s record.
39.3.3.10. The patient’s plan of care is modified, when the patient’s needs change.

Intent of 39.3.4
• identify patients with pain, during the initial assessment and at reassessments;
39.3.4 Criteria
39.3.4.1. The organisation respects and supports the patient’s right to appropriate assessment and
management of pain.
39.3.4.2. The organisation communicates with, and provides education for, patients and their families about
pain and pain management.
39.3.5. Management of the dental service ensures that policies and procedures
relating to dentistry are developed and implemented in accordance with hospital
management’s policies and procedures, according to the following criteria:
39.3.5 Criteria
39.3.5.1. Policies and procedures are developed relating to dental records.
39.3.5.2. Policies and procedures are developed relating to referrals and transfer.
39.3.5.3. Policies and procedures are developed relating to informed consent.
39.3.5.4. Policies and procedures are developed relating to screening and assessment programmes.
39.3.5.5. Policies and procedures are developed relating to general and local anaesthesia.
39.3.5.6. Policies and procedures are developed relating to sedation techniques.
Intent of 39.3.6

decisions. Patients and their families are informed as to what tests, procedures and treatments require
discussed.
39.3.6 Criteria
39.3.6.1. Patients and their families or decision-makers receive adequate information, to enable them to
39.3.6.4. Patients are informed about the potential benefits and drawbacks of the proposed treatment.
39.3.6.7. Patients are informed about any possible problems related to the recovery process.
39.3.6.8. Patients are informed about the possible results of non-treatment.
39.3.6.9. Patients know the identity of the dentist or other practitioner, responsible for their care.
39.3.6.12. Patients and their families participate in care decisions, to the extent they choose.
39.3.6.13. The information provided is recorded, together with the documentation of the patient having provided
written or verbal consent.
39.4. Medication
regulations.
Intent of 39.4.1
experience, and who are permitted by laws, regulations, or registration to prescribe or order


39.4.1 Criteria
dental unit.
39.4.1.5. Only those permitted by the organisation and by relevant laws and regulations, prescribe medication.
individuals.
39.4.1.7. Medications brought into the organisation by the patient or his or her family are known to the patient’s
dentist and noted in the patient’s record.

Intent of 39.4.2
staff training.
39.4.2 Criteria
medications.
39.4.2.6. The organisation has identified those adverse effects that are to be recorded in the patient’s record,
39.4.2.8. Adverse effects are reported, when required.

Intent of 39.4.3

regulation and professional practice standards.
39.4.3 Criteria
39.4.3.1. Medications are stored in a locked storage device or cabinet, which is accessible only to authorised
staff.
39.4.3.5. Medications are stored in accordance with the manufacturer’s instructions relating to temperature,
light and humidity.
39.4.3.9. Expiry dates are checked (including those of emergency drugs), and drugs are replaced before their
expiry dates.

39.5.1. Each patient’s educational needs are assessed and written in his or her
record.
Intent of 39.5.1
Education is provided, to support care decisions of patients and their families. In addition, when a
choices.
Education in areas, which carry high risk to patients, is routinely provided by the organisation, for
Community organisations, which support health promotion and disease prevention education, are
39.5.1 Criteria
39.5.1.1. The patient’s and his/her family’s educational needs are assessed and recorded.
39.5.1.3. Patients and their families learn about participation in the care process.
39.5.1.4. Patients and their families learn about any financial implications of care decisions.
39.5.1.5. Patients are educated about relevant high health risks, e.g. the safe use of medications and medical
equipment, or medications and food interactions.
39.5.1.6. The organisation identifies and establishes relationships with community resources, which support
39.5.2. Education methods consider the patient’s and his/her family’s values and
preferences.

Intent of 39.5.2
Learning occurs, when attention is paid to the methods used to educate patients and their families.
The organisation selects appropriate educational methods and people to provide the education.
39.5.2 Criteria
39.5.2.1. The patient and his/her family are taught in a language and format, which they can understand.
39.5.2.4. Interaction between staff, the patient and his/her family confirms that the information was understood
and is noted in the patient’s record.

Intent of 39.6.1
39.6.1 Criteria
39.6.1.2. Individuals responsible for the patient’s care and its co-ordination are identified for all phases.
39.6.1.4. The record of the patient accompanies the patient, when he or she is transferred within the
organisation.

Intent of 39.6.2
39.6.2 Criteria
39.6.2.2. The transfer process addresses who is responsible during the transfer.
39.6.2.4. The transfer process addresses the patient’s continuing care needs.
39.6.2.5. The referring organisation determines that the receiving organisation can meet the patient’s
continuing care needs, and establishes arrangements to ensure continuity of care.
39.6.2.6. Arrangements are in place with those receiving organisations to which patients are frequently
transferred.

39.6.2.8. Patients are accompanied and monitored by an appropriately qualified person during the transfer.
summary of the patient’s clinical condition and the interventions provided by the referring
organisation.
39.6.2.10. The transferring organisation documents the transfer in the organisation’s patient record.
39.6.2.11. The reason(s) for the transfer is (are) noted in the patient's record.
39.6.2.12. Any special conditions related to the transfer are noted in the patient's record.
39.6.2.13. The condition of the patient before the transfer is noted in the patient's record.
39.6.2.14. The designation of the healthcare organisation, or other internal unit agreeing to receive the patient, is
noted in the patient's record.

outpatient service.
Intent of 39.7.1
39.7.1 Criteria
39.7.1.1. There is a written quality improvement programme for the dental service, which has been developed
39.7.1.4. Processes are selected in order of priority for evaluation of and improvement in the quality of
treatment and care.

39.8.1 Criteria


39.9.1 Criteria
specimens.
infection control.
appropriate, the families and other caregivers.

39.10.1 Criteria
safety programme.
39.10.1.2. There is a programme for the inspection of patient care buildings and a plan to reduce fire risks, for
39.10.1.5. There is a plan, which is implemented, for the safeguarding and protection of buildings, patients, staff
and visitors.

SPECIALISED SERVICES
40.Psychiatric Care (Hospital)
Overview of Psychiatric Care (Hospital)

A healthcare organisation's main purpose is patient care. Providing the most appropriate care in a setting that
supports and responds to each patient's unique needs requires a high level of planning and co-ordination. For
patients requiring psychiatric care special needs apply. It has been shown that the best results are achieved
where the patient is treated by a multidisciplinary team, using the least restrictive environment.
Certain activities are basic to patient care, including planning and delivering care to each patient, monitoring the
patient to understand the results of the care, modifying care when necessary and completing the follow-up. For
individuals in forensic settings, decisions based on court orders must be addressed. The initial assessment and
decision concerning services required or to be provided may be performed by a different organization than the one
providing the comprehensive assessment and treatment.
Many medical, nursing, pharmaceutical, rehabilitation and other types of healthcare providers may carry out these
activities. Each provider has a clear role in patient care. Credentialing, registration, law and regulation, an
individual's particular skills, knowledge and experience, and organisational policies or job descriptions determine
that role. The patient, the family or trained caregivers may carry out some of this care.
A plan for each patient is based on an assessment of needs. That care may be preventive, palliative, curative or
rehabilitative and may include the use of medication, supportive therapies, or a combination of these. A plan of
care is not sufficient to achieve optimal outcomes unless the delivery of the services is co-ordinated, integrated
and monitored.
Non-clinical constraints affect admission, treatment and discharge decisions in organizations providing forensic
services. Such an organization often must accept court-ordered admission and has limited ability to select the
type of individuals it will serve. In addition, such organizations often cannot limit their admissions to individuals
requiring the level of care and services they offer. That is, such organizations are also required by the courts and
the forensic system to admit, to 24-hour care, a significant number of individuals who may not require mental
health services or who could be adequately served on an outpatient or partial-hospitalisation basis if security were
not a concern. Furthermore, such an organization often cannot give individuals increasing freedom (for example
community visits) as part of their treatment programme or discharge them without a court order.
From entry to discharge or transfer, several departments, services and different health care providers may be
involved in providing care. Throughout all phases of care, patient needs are matched with appropriate resources
within and, when necessary, outside the organisation. This is accomplished by using established criteria or
policies that determine the appropriateness of transfers within the organisation.
Processes for continuity and co-ordination of care among psychiatrists and medical practitioners, nurses and other
health care providers must be implemented in and between all services.

Standards

patient's care.
Intent of 40.1.1
The individuals who bear overall responsibility for the patient's care or particular phase of care are
The security of a forensic facility usually is maintained by non-clinically trained staff. These security or
correctional staff often play central roles in the interactions between individuals served and staff, and
therefore can have a therapeutic or anti-therapeutic effect. Staff levels in forensic facilities are such
that security staff must conduct care activities customarily performed by clinically trained staff.
Therefore, in some instances, security needs of individuals may dominate decisions about assigning,
classifying and grouping both facility staff and individuals served within the forensic facility.
40.1.1 Criteria
other staff.
40.1.1.4. The responsibilities and duties of these individuals are written into job descriptions/service contracts.
40.1.1.5. Meetings to discuss patient care/treatment regimes are held by the multidisciplinary team at regular
intervals determined by the organisation.
40.1.1.6. Policies and procedures guide the role of the multidisciplinary team in the development of therapeutic
programmes.
40.1.1.7. Policies and procedures guide the role of the multidisciplinary team in case review.
40.1.1.8. Policies and procedures guide the role of the primary therapist in the multidiscilplinary team.
40.1.1.9. Security or correctional staff are made aware of their responsiblilities in relation to their response to
unusual clinical events.
40.1.1.10. Security or correctional staff are made aware of their responsibilities in relation to the organisation's
channels of clinical, security and administrative communication.
40.1.1.11. Security or correctional staff are made aware of their responsibilities in relation to the distinction
between administrative and clinical seclusion and/or restraint.
40.1.2. The delivery of sevices is integrate and co-ordinated amongst members of

the multidisciplinary care team.
Intent of 40.1.2
The co-ordination of patient care depends on the exchange of information between members of the
appropriate policies determined by the organisation.
The multidisciplinary team must consist of a psychiatrist, psychiatric nurse and social worker with
access to a psychologist, occupational therapist and physiotherapist, where the client's condition
warrants it.
Clinical leaders should use techniques to better integrate and co-ordinate care for their patients (for
example, team-delivered care, multi-departmental patient care rounds, combined care planning
forums, integrated patient records, case managers). The process for working together will be simple
and informal when the patient's needs are not complex.

40.1.2 Criteria
40.1.2.1. There is a multidisciplinary approach to the development and implementation of a therapeutic
programme
40.1.2.2. The care management system is designed to assure co-ordinated participation of all appropriate
healthcare professionals.
40.1.2.3. A psychiatrist heads the multidisciplinary team.
40.1.2.4. The team consists of appropriately qualified personnel, including representatives from the medical,
nursing, social work, psychology, occupational therapy, physiotherapy and other disciplines,
departments or services, as appropriate.
40.1.2.5. The team members' responsibilities include development and implementation of a comprehensive,
individualised plan of care for each patient, based on the assessment of the patient.
40.1.2.6. The team conducts periodic re-evaluation of each patient's plan of care to determine whether
established goals are being or have been met and whether change in the patient's condition requires
modification of goals.
40.1.2.7. The team includes the patient and his/her family in the development and review of the plan of care, as
appropriate.
40.1.2.8. The multidisciplinary team meets regularly to co-ordinate patient care.
40.1.2.9. Policies define the multidisciplinary recording of patient assessment and care.
40.1.3. The patient's record is available to the care providers to facilitate the
exchange of information.
40.1.3 Criteria

indentified through and established assessent process.
Intent of 40.2.1
provided.
40.2.1 Criteria
ongoing care
40.2.1.2. The organisation has defined admission criteria for the psychiatric service, which are known to the
staff.

40.2.1.3. Admission criteria include the removal of potentially harmful articles for safe-keeping.
assessments.
40.2.2. Clinical practice guidelines are used to guide patient assessent and reduce
unwanted variation.
Intent of 40.2.2
clinical decisions. Regardless of the source, the scientific basis of guidelines should be reviewed and
approved by organisation leaders and clinical practitioners before implementation. This ensures that
they meet the criteria established by the leaders and are adapted to the community, patient needs and
40.2.2 Criteria
40.2.2.4. Guidelines are reviewed and adapted on a regular basis after implementation
40.2.3. Assessment are performed within appropriate time frames.

Intent of 40.2.3
40.2.3 Criteria
procedures and guidelines in terms of current legislation.
Intent of 40.2.4
necessary.

The outcome from the patient's initial assessment is an understanding of the patient's medical,
nursing and therapeutic needs so that care and treatment can begin.
40.2.4 Criteria
40.2.4.4. The initial assessment by the medical and nursing staff includes health history.
40.2.4.5. The initial assessment by the medical and nursing staff includes physical examination.
40.2.4.6. The initial assessment by the medical and nursing staff includes functional and nutritional assessment
where the need is identified.
40.2.4.7. The initial assessment by the medical and nursing staff includes mental status examination.
40.2.4.8. The initial assessment by the medical and nursing staff includes psychological assessment should the
patient's condition warrant it.
40.2.4.9. The initial assessment by the medical and nursing staff includes social, cultural and economic
assessment.
40.2.4.10. The initial assessment by the medical and nursing staff includes assessment by social worker, where
appropriate.
40.2.4.14. The initial assessment results in the identification of the patient's medical, nursing and therapeutic
needs.
40.2.5. Pre-anaesthetic assessments are documented

Intent of 40.2.5
Psychiatric patients sometimes receive anaesthesia for electroconvulsive therapy.
planned anaesthetic. The clinical assessment and results of investigations must be available to the
doctor performing the assessment.
40.2.5 Criteria
marrow aspiration, lumbar puncture etc. under anaesthesic.


Intent of 40.2.6
40.2.6 Criteria
patient's care.
40.3. Patient Care

40.3.1. Adequate resources are available for the provision of a safe and therapeutic
milieu for patients in the service.
Intent of 40.3.1
Oxygen and vacuum are adequately supplied to meet the needs of the patients. Where there is no
piped oxygen and vacuum supply, there are mobile oxygen and vacuum pumps. All necessary fittings
for oxygen and suction are in place and working satisfactorily. Each bed is serviced by at least one
electrical socket outlet. Each ward is provided with a socket outlet, which is connected to the
A therapeutic milieu contributes to the recovery of the patient. The facilities should be equipped with
domestic furniture and designed to create a home-like atmosphere. Such facilities should include
• Designated lounge and recreation facilities
• Communal dining room
• Therapy rooms
• Space for physical/exercise activities
• Outdoor/garden space
• Designated smoking area, which meets legal requirements
• Patient rooms, which ensure privacy
The design of the buildings and the fixtures and fittings should be of such a nature as to prevent their
contribution to the injury of patients or staff, for example by patients breaking off fittings and using
them as weapons.
Although physically ill patients must be referred to another appropriate facility, resuscitation equipment
is immediately available from each section of the ward. Resuscitation equipment includes at least:

• Defibrillator with appropriate paddles

• ECG monitor
• CPR board
• Suction
• Oral airways
• appropriate facilities for intravenous therapy and drug administration;
• drugs for cardiac and respiratory arrest, coma, fits and states of shock;
40.3.1 Criteria
40.3.1.1. Staff accommodation in the service is adequate to meet patient care needs and includes at least
adequate private consulting rooms.
40.3.1.2. Staff accommodation in the service is adequate to meet patient care needs and includes at least an
alarm system (panic button) in each consulting room.
alarms for medical emergencies.
alarms for security threats.
40.3.1.5. Patient accommodation and equipment is adequate to meet the needs of patients and includes at
least socialization areas.
least outdoor areas.
least adequate, suitably furnished, dining rooms.
least sufficient recreational equipment to meet patient needs.
least designated smoking areas.
40.3.1.10. There is evidence of a homely, non-clinical atmosphere.
40.3.1.11. Arrangements are in place for patients to wear their own clothes, where appropriate.
40.3.1.12. There are safe and secure facilities to meet the special needs of forensic service patients.
40.3.1.16. Where there is no piped oxygen installation, there is a documented procedure for ensuring that
record.
Intent of 40.3.2


40.3.2 Criteria
40.3.2.4. All procedures and diagnostic tests ordered and performed, are written into the patient's record.

Intent of 40.3.3
needs.
There is a structured therapeutic environment, which allows for group therapy, occupational therapy, or
40.3.3 Criteria
40.3.3.2. There is documented participation in a structured therapeutic programme six to seven hours per day.
40.3.3.5. The patient has the least restrictive environment possible according to policy, with any restrictions
placed upon him/her written into the treatment plan.
40.3.4. There are mechanisms designed to facilitate communication and resolve

conflict between judicial, correctional, penal, clinical and administrative agencies and
those involved in an individual's care.
Intent of 40.3.4
Non-clinical constraints can affect admission, treatment and discharge decisions in organizations
providing forensic services. When conflict with security and individual needs occur, staff develop an
adapted plan to simulate normalized experiences.
40.3.4 Criteria
40.3.4.1. Legal, correctional, and/or administrative decisions affecting an individual's treatment are coordinated
with clinical decisions related to use of seclusion and restraint for nonclinical purposes.
40.3.4.2. Legal, correctional, and/or administrative decisions affecting an indivudual's treatment are
coordinated with clinical decisions related to imposition of disciplinary restrictions.
coordinated with clinical decisions related to length of stay.

coordinated with clinical decisions related to restriction of rights.
coordinated with clinical decisions related to plan for discharge and continuing care.

Intent of 40.3.5
decisions.
40.3.5 Criteria
management of pain.
pain management.
40.3.5.4. Patients with pain are sent for physical assessment.
40.3.5.5. The organisation respects the need of the physically ill or dying patient to be transferred to another
suitable facility/unit.
Intent of 40.3.6
needs. Psychiatric patients are commonly in this group as they may not speak for themselves,
understand the care process or participate in decisions regarding their care.
Policies and procedures are important for staff to understand high-risk patients and services, and to

• availability and use of resuscitation equipment.

40.3.6 Criteria
40.3.6.4. Policies and procedures guide the obtaining of informed consent.
40.3.6.5. Policies and procedures guide diagnostic investigations.
40.3.6.6. Policies and procedures guide the standard of clothing provided to patients.
40.3.6.7. Policies and procedures guide the use of behaviour modification techniques.
40.3.6.8. Policies and procedures guide observation of patients treated for eating disorders.
40.3.6.9. Policies and procedures guide management of the detoxification stage of treatment.
40.3.6.10. Policies and procedures guide the management of patients who may be a danger to themselves or
others.
40.3.6.11. Policies and procedures guide the administration of electro-convulsive therapy.
40.3.6.12. Policies and procedures guide management of the violent patient.
40.3.6.13. Policies and procedures guide the management of complaints from patient, families, visitors, staff and
the public.
40.3.6.14. Policies and procedures guide the searching of patients, visitors, parcels and staff for weapons and
drugs.
40.3.6.15. Policies and procedures specify the management of restraint and seclusion in relation to the
handling, storage, use and administration of mechanical restraints.
handling, storage, use and administration of chemical restraints.
40.3.6.17. Policies and procedures specify the management of restraint and seclusion in relation to the care of
patients being restrained.
40.3.6.18. Policies and procedures specify the management of restraint and seclusion in relation to the keeping
of records of patients being restrained.
40.3.6.19. Policies and procedures specify the management of restraint and seclusion in relation to the care of
patient in seclusion.
documentation required for patients in seclusion.
40.3.6.21. Policies and procedures specify the management of patient referred by the courts in relation to the
observation of patients referred by the court.
keeping of records.
submission of reports.
40.3.7. Risks benefits, potential complications and care options are discussed with
Intent of 40.3.7

• an explanation of the risks and benefits of the planned tests, treatment or procedure;
• consideration of the options available for treatment.
understanding of the information. The patient's psychiatrist or other qualified individual provides the
40.3.7 Criteria
hospitals.
40.3.7.10. Patients know the identity of the psychiatrist or other practitioner responsible for their care.
consent.
40.4. Medication
40.4.1. Medication use in the orginsation complies with applicable laws and
regulations.
Intent of 40.4.1
experience, and who are permitted by law, registration, or regulations to prescribe or order
prescribed, and using verbal medication orders is defined in policy.
40.4.1 Criteria
patient care unit.


individuals.
40.4.1.7. There is evidence that, where appropriate, blood levels of medications are checked in accordance
with manufacturers' instructions before prescribing.
40.4.1.8. Medications, including herbal and over-the-counter medications, brought into the organisation by the
patient or family are immediately taken into safe custody and noted in the patient's record.

Intent of 40.4.2
staff training.
40.4.2 Criteria
medications.
40.4.3. Medication is stored in a locked storage device or cabinet that is accessible

only to authorised staff.
Intent of 40.4.3
Patient care units store medications in a clean and safe environment that complies with law,
40.4.3 Criteria

humidity.
date.

Intent of 40.5.1
40.5.1 Criteria

40.6.1. Each patient's educational needs are assessed and written in their record.
Intent of 40.6.1


40.6.1 Criteria
preferences.
Intent of 40.6.2
40.6.2 Criteria

Intent of 40.7.1
40.7.1 Criteria
40.7.1.5. Documentation regarding the transfer of a patient from the forensic service to another service within
the hospital meets legal requirements


Intent of 40.7.2
40.7.2 Criteria
transferred.
organisation.
patient's record.

Intent of 40.7.3
possible. Instructions for discharge and follow-up visits to other facilities must be clear and provided in
writing.
40.7.3 Criteria
40.7.3.3. The organisation determines the circumstances under which the patient may be prematurely
discharged.
40.7.3.7. Patients and, as appropriate, their families are given understandable follow-up instructions by the
medical practitioner in the discharge note at referral or discharge.
care.
40.7.3.9. Documentation regarding the discharge (whether temporary or permanent) of a patient from a
forensic service meets legal requirements.
patient's record.

Intent of 40.7.4
40.7.4 Criteria
40.7.4.1. A discharge summary is written, by the medical practitioner, on the discharge of each patient.
40.7.4.13. The discharge summary complies with legal documentary requirements.
40.8. Quality Improvement

40.8.1. A formalised pro-active quality improvement approach is maintained in the
psychiatric service.
Intent of 40.8.1
40.8.1 Criteria
40.8.1.1. There is a written quality improvement programme for the psychiatric service that is developed and
and care.


40.9.1 Criteria
40.9.1.2. Patients and families must be informed of their rights as detailed in the local legislation (e.g. Mental
Healthcare Act No. 17 of 2002.)
40.9.1.3. The patient and family, or authorised legal representative, must be consulted throughout the care
process.
40.9.1.8. Patients are informed of their right to participate in research.

40.10.1 Criteria
specimens.
infection control.

40.11.1 Criteria
safety programme.
and visitors.
40.11.1.6. The plan specifies risks specific to psychiatric care e.g. measures to reduce suicide risk.
40.12. Child and family service

40.12.1. The delivery of services is integrated and co-ordinated amongst members of

Intent of 40.12.1
The multidisciplinary team must consist of a psychiatrist, psychiatric nurse and occupational therapist,
with access to a psychologist, social worker and physiotherapist, where the client's condition warrants
it. Care sometimes requires that people other than, or in addition to, the individual served be involved
in decisions about the individual's care. In the case of an un-emancipated minor, the family or
guardian is legally responsible for approval of care.
40.12.1 Criteria
programme.
nursing, social work, psychology, occupational therapy and other disciplines, departments or services,
as appropriate.
appropriate.
40.12.1.1 Care planning is integrated and co-ordinated among all care providers.
0.
40.12.2 Criteria
40.12.3. Each patient and family has an initial assessment that complies with current
policies, procedures and guidelines in terms of current legislation.

Intent of 40.12.3
To facilitate timely, appropriate and continuous post-discharge care, assessments are conducted to
support discharge planning. When indicated, this planning begins when the individual enters the care
setting. Patients' social, cultural and family status are important factors that can influence their
response to illness and care. Families can be of considerable help in these areas of assessment and
in understanding the patient's wishes and preferences. Economic factors are assessed as part of the
necessary.
Certain patients may require a modified assessment, eg very young patients, the frail or the psychotic,
depressed or suicidal, those terminally ill or in pain, patients suspected of drug and/or alcohol
dependency, and victims of abuse and neglect. The assessment process is modified in accordance
with local laws and regulations, the culture of the patient population, and involves the family when
appropriate.
A psychosocial assessment of the child receiving inpatient, residential, partial-hospitalisation,
continuing outpatient, home care or case-management services and his or her family includes an
evaluation of the effect of the family or guardian on the condition of the individual served and the effect
of the condition on the family or guardian. As part of the assessment process, the organization
identifies the adult(s) who has legal custody e.g. in the case of divorced parents. This may prevent
conflicts during care or discharge planning that can be detrimental to the child.
nursing, therapeutic and psychosocial needs so that care and treatment can begin.
40.12.3 Criteria
40.12.3.1. Each patient and family has an initial assessment that meets organisation policy.
40.12.3.2. The findings of assessments of the patient's and family's condition performed outside the organisation
are verified on admission.
40.12.3.3. Any significant changes in the patient's and family's condition since the initial assessment are noted in
the patient's record.
40.12.3.5. The initial assessment includes history of head injury.
40.12.3.6. The initial assessment includes physical examination of the child.
40.12.3.7. The initial assessment includes developmental history of the child.
40.12.3.8. The initial assessment includes functional assessment of the child.
40.12.3.9. The initial assessment includes mental status examination.
40.12.3.1 The initial assessment includes nutritional assessment of the child.
0.
40.12.3.1 The initial assessment includes psychological and behavioural assessment of the child.
1.
40.12.3.1 The initial assessment includes assessment of family functioning.
2.
40.12.3.1 The initial assessment includes social, cultural and economic assessment.
3.

40.12.3.1 The initial assessment includes a genogram of family construction.

4.
40.12.3.1 The initial assessment includes assessment by social worker, where appropriate.
5.
40.12.3.1 The initial assessment includes collateral information from outside sources, where appropriate e.g.
6. crèche of school.
40.12.3.1 The initial assessment results in an understanding of the care the family is seeking.
7.
40.12.3.1 The initial assessment results in an understanding of any previous care.
8.
40.12.3.1 The initial assessment results in an initial diagnosis.
9.
40.12.3.2 The initial assessment results in the identification of the patient's medical, nursing and therapeutic
0. needs.
40.12.3.2 The organisation identifies those patient populations and special situations for which the initial
1. assessment process is modified.
40.12.3.2 The organisation identifies patients in pain during the assessment process.
2.
40.12.3.2 Special patient populations receive individualised assessments.
3.
40.12.3.2 Possible victims of abuse or neglect are identified using criteria developed by the organisation.
4.
40.12.3.2 A process is in place to identify needs for discharge planning at the initial assessment.
5.

Intent of 40.12.4
needs.
40.12.4 Criteria
40.12.4.4. The patient has the least restrictive environment possible, with any restrictions placed upon him/her
written into the treatment plan.
Intent of 40.12.5

• options available to treat the patient.

discussed.
40.12.5 Criteria
40.12.5.3. Patients and their families are informed about their condition and the proposed treatment.
40.12.5.4. Patients and their families are informed about potential benefits and drawbacks to the proposed
treatment.
40.12.5.5. Patients and their families are informed about the possible alternatives to the proposed treatment.
40.12.5.6. Patients and their families are informed about the likelihood of successful treatment.
40.12.5.7. Patients and their families are informed about possible problems related to recovery.
40.12.5.8. Patients and their families are informed about possible results of non-treatment.
40.12.5.9. Patients and their families know the identity of the psychiatrist or other practitioner responsible for
their care.
40.12.5.1 When treatments or procedures are planned, patients and their families know who is authorised to
0. perform the procedure or treatment.
40.12.5.1 The information is provided to patients in a clear and understandable way.
1.
40.12.5.1 Patients and families participate in care decisions to the extent they choose.
2.
40.12.5.1 The information provided is recorded, with the record of the patient's parent or guardian having
3. provided written or verbal consent.
40.13. Adolescent Service

Intent of 40.13.1
it.

40.13.1 Criteria
programme.
as appropriate.
appropriate.
0.
40.13.2 Criteria
40.13.3. Each patient and family has an initial assessment that complies with current
policies, procedures and guidelines in terms of the current legislation
Intent of 40.13.3
To facilitate timely, appropriate and continuous post-discharge care, assessments are conducted to
support discharge planning. When indicated, this planning begins when the individual enters the care
setting. Patients' social, cultural and family status are important factors that can influence their
necessary.
Certain patients may require a modified assessment, eg very young patients, the frail, the psychotic ,
depressed or suicidal, those terminally ill or in pain, patients suspected of drug and/or alcohol

appropriate.
A psychosocial assessment of the adolescent receiving inpatient, residential, partial-hospitalisation,
continuing outpatient, home care or case-management services and his or her family includes an
evaluation of the effect of the family or guardian on the condition of the individual served and the effect
of the condition on the family or guardian. As part of the assessment process, the organization
identifies the adult(s) who has legal custody e.g. in the case of divorced parents. This may prevent
conflicts during care or discharge planning that can be detrimental to the adolescent.
nursing, therapeutic and psychosocial needs so that care and treatment can begin.
40.13.3 Criteria
40.13.3.1. Each patient and family has an initial assessment that meets organisation policy.
40.13.3.2. The findings of assessments of the patient's and family's condition performed outside the organisation
are verified on admission.
40.13.3.3. Any significant changes in the patient's and family's condition since the initial assessment are noted in
the patient's record.
40.13.3.5. The initial assessment includes history of head injury.
40.13.3.6. The initial assessment includes drug history, including alcohol.
40.13.3.7. The initial assessment includes physical examination of the adolescent.
40.13.3.8. The initial assessment includes developmental history of the adolescent.
40.13.3.9. The initial assessment includes functional assessment of the adolescent.
40.13.3.1 The initial assessment includes mental status examination.
0.
40.13.3.1 The initial assessment includes nutritional assessment of the adolescent.
1.
40.13.3.1 The initial assessment includes psychological and behavioural assessment of the adolescent.
2.
3.
4.
5.
6.
7. school.
40.13.3.1 The initial assessment results in an understanding of the care the patient and family is seeking.
8.
9.
0.
1. needs.
3.
4.

40.13.3.2 Possible victims of abuse or neglect are identified using criteria developed by the organisation.
5.
6.

Intent of 40.13.4
needs.
40.13.4 Criteria
40.13.5. Risks, benefits complications and care options are discussed with the
patient and his or her family or with those who make decisions for the patient.
Intent of 40.13.5
• options available to treat the patient.
discussed.
40.13.5 Criteria


40.13.5.3. Patients and their families are informed about their condition and the proposed treatment.
40.13.5.4. Patients and their families are informed about potential benefits and drawbacks to the proposed
treatment.
40.13.5.5. Patients and their families are informed about the possible alternatives to the proposed treatment.
40.13.5.6. Patients and their families are informed about the likelihood of successful treatment.
40.13.5.7. Patients and their families are informed about possible problems related to recovery.
40.13.5.8. Patients and their families are informed about possible results of non-treatment.
40.13.5.9. Patients and their families know the identity of the psychiatrist or other practitioner responsible for
their care.
40.13.5.1 When treatments or procedures are planned, patients and their families know who is authorised to
0. perform the procedure or treatment.
40.13.5.1 The information is provided to patients in a clear and understandable way.
1.
40.13.5.1 Patients and families participate in care decisions to the extent they choose.
2.
40.13.5.1 The information provided is recorded, with the record of the patient's parent or guardian having
3. provided written or verbal consent.
40.14. Care of the Intellectually Disabled

Intent of 40.14.1
The co-ordination of clients/residents care depends on the exchange of information between the
with access to a psychologist, social worker and physiotherapist, where the clients/residents' condition
warrants it.
Clinical leaders should use techniques to better integrate and co-ordinate care for their
clients/residents (for example, team-delivered care, multi-departmental clients/residents care rounds,
combined care planning forums, integrated clients/residents records, case managers). The process
for working together will be simple and informal when the clients/residents' needs are not complex.
The clients/residents, family and others are included in the decision process when appropriate.
The clients/residents' record contains a history of all care provided by the multidisciplinary team and is
made available to all relevant caregivers who are authorised to have access to its content.
40.14.1 Criteria
programme
as appropriate.
individualised plan of care for each patient, based on the assessment of the patient
appropriate.


0.
40.14.2. The clients/residents' record is available to the care providers to facilitate

the exchange of information.
40.14.2 Criteria
40.14.2.2. Information exchanged includes the clients/residents' health status.
40.14.2.4. Information exchanged includes the clients/residents' progress.
40.14.2.5. The author can be identified for each clients/residents record entry.
40.14.2.6. The date of each clients/residents record entry can be identified.
40.14.3. Each clients/resident and family has an initial assessment that complies with
current policies, procedures and guidelines in terms of current legislation.
Intent of 40.14.3
The initial assessment of a client/resident is critical for the identification of the needs of the
clients/residents and initiation of the care process. Planning for discharge is initiated during the initial
assessment process. Clients'/residents' physical, emotional, spiritual, social, cultural and family status
are important factors that can influence their response to illness and care. Families can be of
considerable help in these areas of assessment and in understanding the clients/residents' wishes and
preferences. Economic factors are assessed as part of the social assessment, particularly when the
clients/residents and his/her family will be responsible for the cost of all or a portion of the care.
A functional and nutritional assessment allows for the clients/residents to be referred for specialist care
if necessary.
Certain clients/residents may require a modified assessment, eg very young clients/residents, the frail
or the elderly, those with impaired intellectual ability or emotional state, those terminally ill or in pain,
clients/residents suspected of drug and/or alcohol dependency, and victims of abuse and neglect.
The assessment process is modified in accordance with local laws and regulations, the culture of the
clients/residents population, and involves the family when appropriate.
The outcome from the clients/residents' initial assessment is an understanding of the clients/residents'
medical , nursing and therapeutic needs so that care and treatment can begin.
clients/residents' record. Any significant changes in the clients/residents' condition since the
assessment are recorded.
40.14.3 Criteria
40.14.3.1. Each clients/residents and family has an initial assessment that meets organisation policy.
40.14.3.2. The findings of assessments of the clients/residents' and family's condition performed outside the
organisation are verified on admission.
40.14.3.3. Any significant changes in the clients/residents' and family's condition since the initial assessment are
noted in the clients/residents' record.
40.14.3.4. The initial assessment includes health history, including history of head injury.
40.14.3.5. The initial assessment includes drug history, if relevant.

40.14.3.6. The initial assessment includes scholastic history, if relevant.

40.14.3.7. The initial assessment includes physical examination .
40.14.3.8. The initial assessment includes developmental history .
40.14.3.1 The initial assessment includes functional assessment of the client/resident.
0.
40.14.3.1 The initial assessment includes nutritional assessment of the client/resident.
1.
40.14.3.1 The initial assessment includes psychological and behavioural assessment of the client/resident.
2.
3.
4.
40.14.3.1 The initial assessment includes assessment by social worker.
5.
6.
40.14.3.1 The initial assessment includes functional assessment of the family.
7.
8. crèche of school.
40.14.3.1 The initial assessment includes identification of community resources already involved.
9.
40.14.3.2 The initial assessment includes identification of legal intervention, if applicable.
0.
40.14.3.2 The initial assessment results in an understanding of the care the family is seeking.
1.
2.
3.
40.14.3.2 The initial assessment results in the identification of the clients/residents' therapeutic and
4. rehabilitation needs.
40.14.3.2 The organisation identifies those clients/residents populations and special situations for which the
5. initial assessment process is modified.
40.14.3.2 The organisation identifies clients/residents in pain during the assessment process.
6.
40.14.3.2 Special clients/residents populations receive individualised assessments.
7.
40.14.3.2 A process is in place to identify possible future needs for home-based care at the initial assessment.
8.
40.14.4. Healthcare professionals responsible for clients/residents care collaborate

to analyse and integrate assessment information.
Intent of 40.14.4
A clients/residents benefits most when the staff responsible for the clients/residents work together to
analyse the assessment findings and to combine this information into a comprehensive picture of his
or her condition. From this collaboration, the clients/residents' needs are identified, the order of their
importance is established, and care decisions are made.
40.14.4 Criteria
40.14.4.1. Assessment findings are documented in the clients/residents' record and are readily available to
those responsible for the clients/residents' care.
40.14.4.2. Clients/residents assessment data and information are analysed and integrated by those responsible
for the clients/residents' care.
40.14.4.3. Clients/residents needs are prioritised on the basis of assessment results.

40.14.4.4. The clients/residents and/or his or her family participate in the decisions regarding the priority needs
to be met.

Intent of 40.14.5
needs.
40.14.5 Criteria
40.15. Rehabilitation service

Intent of 40.15.1
it.
40.15.1 Criteria
programme.
as appropriate.

appropriate.
40.15.1.1 Care planning is integrated and coordinated among all care providers.
0.
40.15.2 Criteria
40.15.3. Each patient has an initial assessment, which complies with current policies,
Intent of 40.15.3
necessary.
Certain patients may require a modified assessment, e g very young patients, the frail or the elderly,
those terminally ill or in pain, patients suspected of drug and/or alcohol dependency, and victims of
abuse and neglect. The assessment process is modified in accordance with local laws and
regulations, the culture of the patient population, and involves the family when appropriate.
The outcome from the patient's initial assessment is an understanding of the patient's medical, nursing
and therapeutic needs so that care and treatment can begin.
40.15.3 Criteria
40.15.3.1. Each patient has an initial assessment that meets organization policy.

40.15.3.5. The initial assessment includes mental status examination

40.15.3.6. The initial assessment includes psychological assessment should the patient's condition warrant it.
40.15.3.8. The initial assessment includes assessment of suitability for treatment in the rehabilitation service.
0.
1.
40.15.3.1 The initial assessment results in the identification of the patient's medical and therapeutic needs.
2.

Intent of 40.15.4
needs.
40.15.4 Criteria
40.15.4.7. Those special patient populations receive individualised assessments.
40.16. Volunteer Service

40.16.1. The voluteer service is organised, managed and staffed to provide a safe
and effective service and is co-ordinated with other staff and services within the care
centre.
Intent of 40.16.1
complex.

40.16.1 Criteria
40.16.1.1. A suitably qualified and experienced health professional is identified with clearly defined and
documented responsibilities for co-ordination of the volunteer service.
40.16.1.2. The manager is represented on the volunteers' management committee to act as liaison between the
care centre and the volunteer service.
40.16.1.3. Meetings between the centre management and volunteers' management are held at least monthly.
40.16.1.4. Minutes of these meetings are recorded.
40.16.1.5. There is a current organisational chart, which clearly states the agreed upon lines of communication,
authority, responsibility and accountability.
40.16.1.6. There is evidence that volunteers are selected in accordance with the necessary and appropriate
skills to support the objectives of the volunteer service.
40.16.1.7. Volunteers are clearly identified by name badges.
40.16.1.8. Staff employed in the volunteer service are assigned on the basis of qualification, experience and
interest.
40.16.1.9. There is a mechanism to ensure that all volunteers work under the guidance of suitably qualified
health professionals in the employ of the care centre.
40.16.1.1 The volunteer service is supported by administrative, auxiliary and secretarial staff who may
0. themselves be volunteers.
40.16.1.1 There is a system in place to evaluate the performance of volunteers.
1.
40.16.1.1 There is a system in place to provide acknowledgement and appreciation for services rendered by
2. each volunteer.
40.16.2. Volunteers sign a memorandum of agreement to abide by sthe conditions of

the centre.
40.16.2 Criteria
40.16.2.1. The agreement includes indemnity and waiver for injuries sustained on the premises.
40.16.2.2. The agreement includes the maintaining of confidentiality and privacy of information.
40.16.2.3. The agreement includes abiding by the policies and procedures, which guide the functioning of the
organisation.
40.16.2.4. The agreement includes those functions, which may be carried out by volunteers.
40.16.2.5. The agreement includes access to premises and facilities by volunteers.
40.16.2.6. Agreements are regularly reviewed, dated and amended if needed
40.16.3. There are written policies and procedures for the activities of the volunteer
service.
40.16.3 Criteria
40.16.3.1. The volunteer service has written policies and procedures to guide volunteers in the activities and
management of the volunteer service.
40.16.3.2. Volunteers are involved in the formulation of policies and procedures as well as protocols for
volunteer service.
40.16.3.3. Policies and procedures relate to the scope and functions of volunteers.
40.16.3.4. Policies and procedures relate to the raising funds by volunteers.
40.16.3.5. Policies and procedures relate to the accounting and auditing of finances accrued and managed by
volunteers.
40.16.3.6. Policies and procedures relate to volunteers accompanying residents out of the care centre.
40.16.3.7. Policies and procedures relate to accidents and incidents in the volunteer service.
40.16.3.8. Policies and procedures relate to information to the media.
40.16.3.9. All policies and procedures are dated, signed and have a review date.
40.16.3.1 Policies and procedures are kept in a manual, which is indexed and easily accessible.
0.
40.16.3.1 There is a mechanism to ensure that all policies and procedures are known and implemented by all
1. volunteers working in the volunteer service.

40.16.4. Facilities and equipment are adequate to ensure the provision of safe,
efficient and effective operation of the volunteer service.
40.16.4 Criteria
40.16.4.1. The volunteer service management staff are included in the management committee of the care
centre to advise on planning for equipment acquisition, deployment, utilization and maintenance for
the volunteer service.
40.16.4.2. Telephones are available for volunteers and visitors.
40.16.4.3. There is an alarm system in place in case of medical emergencies, which is known to all members of
the volunteer service.
40.16.4.4. There is an alarm system in place in case of security threats, which is known to all members of the
volunteer service.
40.16.4.5. There is office facility available for the volunteer service manager.
40.16.4.6. There is office facility available for the volunteer service manager.
40.16.4.7. There is adequate light and ventilation in therapy areas.
40.16.4.8. There is adequate and suitable equipment to provide appropriate stimulation to the patients.
40.16.4.9. There is adequate storage space for all equipment, appliances and tools.
40.16.4.1 All furnishing and equipment are clean and in good condition to ensure the safety of patients and
0. volunteers.
40.16.5. Management of the facility, in co-operation with voluteers, ensures that

there is a written, planned and organized development and education programme for
all volunteers.
40.16.5 Criteria
40.16.5.1. There is written, planned orientation and induction programme for all new volunteers to the service.
40.16.5.2. The orientation and induction programme introduces new volunteers to the relevant aspects of the
volunteer service.
40.16.5.3. The orientation and induction programme explains the relationship and line of communication within
the service and the care centre.
40.16.5.4. The orientation and induction programme prepares volunteers for their roles and responsibilities.
40.16.5.5. The orientation and induction programme introduces volunteers to the policies and procedures of the
service and the care centre.
40.16.5.6. The orientation and induction programme ensures the new volunteers are fully informed of the
conditions of confidentiality and conditions of providing information to the media.
40.16.5.7. The orientation and induction programme is reviewed annually, signed and dated.
40.16.6. The service facilitates the development of volunteers to assume increasing

responsibility and leadership within the volunteer service.
40.16.6 Criteria
40.16.6.1. The volunteer service provides a relevant, written in-service training programme for volunteers.
40.16.6.2. The volunteer service ensures that the volunteers are kept up to date with relevant new information.
40.16.6.3. The volunteer service manager ensures that all volunteers are able to initiate basic life support as
necessary.
40.16.6.4. The volunteer service manager ensures that all volunteers are familiar with the care centre's internal
and external incident plans and attend rehearsals at least annually.
40.16.6.5. The volunteer service manager ensures that all volunteers are trained in the relevant health and
safety policies and infection control policies.
40.16.6.6. There is a system in place to ensure that all volunteers attend in-service training programmes, and
that records are kept.
40.16.7. Within the existing constraints of the care centre, the volunteers aim to
promote the psychosocial, physical and spiritual well-being of the patients.

40.16.7 Criteria
40.16.7.1. The functions of the volunteers relating to patient care are clearly defined and supervised.
40.16.7.2. The volunteer services bring specific matters relating to the health of patients to the attention of the
medical and/or nursing staff.
40.16.7.3. Reports on volunteer involvement in group and individual resident stimulation are provided by
volunteers to support further clinical decisions.
40.16.7.4. Reporting on patient progress to the multidisciplinary team is done on a regular basis.
40.17. Electro-convulsive therapy

40.17.1. The electro-convulsive therapy service is managed and staffed to provide a
safe and effective service.
Intent of 40.17.1
Electro-convulsive therapy carries high risk. The collaboration between staff in the therapy unit, health
and safety staff and those responsible for the supply and maintenance of equipment is essential.
Electro-convulsive therapy staff work with organisation leaders to ensure adequate and suitable
management processes and staffing of the unit.
The qualifications of those persons who administer anaesthesia in the hospital are documented in
accordance with current professional society standards.
40.17.1 Criteria
40.17.1.1. A senior professional who is suitably qualified and experienced is in charge of the electro-convulsive
therapy (ECT) service.
40.17.1.2. Electro-convulsive therapy rosters ensure that registered nurses with suitable qualifications and
experience are present at all shifts for electro-convulsive therapy unit duties.
40.17.1.3. Anaesthesia is administered only by qualified anaesthetists.
40.17.1.4. The anaesthetist is directly responsible for only one anaesthetic at a time.
40.17.1.5. The medical practitioner performing the procedures is available before the anaesthesia commences.
40.17.1.6. Nursing staff, who are trained and experienced in the administration of electro-convulsive therapy are
available until the patient has fully recovered.
40.17.2. Clinical practice guidelines are used to guide patient assessment and
reduce unwanted variation.
Intent of 40.17.2
Because convulsive therapies raise societal and individual rights concerns, fully documented and fully
informed consent is essential to protect individuals served, staff and the organisation. Professional
guidelines must be available to staff, and closely followed.
40.17.2 Criteria

40.17.2.2. Guidelines for the assessment of patients and families are implemented.
40.17.3. Facilities for safe anaesthetic care are provided and maintained.
Intent of 40.17.3
Electro-convulsive therapy is a form of somatic treatment that uses electricity to evoke a convulsive
response. Electro-convulsive therapy is a non-invasive procedure, which is carried out under general
anaesthesia. A full-scale operating theatre is not used and everything used, except for injection
equipment, is "surgically clean" rather than "sterile
The design of the ECT treatment area provides space for the reception, anaesthesia, treatment,
There are areas for the disposal and collection of used equipment and waste, including contaminated
waste and sharps. Safe and adequate storage space for pharmaceutical and surgical supplies is
available, including separate lockable cupboards for scheduled substances and other scheduled
medicines and for inflammables.
Staff are provided with office facilities or a day station, a restroom, washrooms and toilets. This may
be a self-contained unit or a unit/room attached to a ward.
40.17.3 Criteria
40.17.3.1. The design of the ECT treatment area provides space for the reception, anaesthesia, treatment,
40.17.3.2. There is direct access to the treatment room from the recovery area.
40.17.3.3. There is safe and adequate storage space for pharmaceutical and surgical supplies.
40.17.3.4. Access to the ECT treatment room is controlled.
40.17.3.5. There is access to disinfection facilities.
40.17.4. Anaesthetic equipment, supplies and medications used comply with the
recommendations of anaesthesia professional organisations or alternate authoritative
sources.
Intent of 40.17.4
Anaesthesia risks are significantly reduced when appropriate and well-functioning equipment is used
to administer anaesthesia and monitor the patient. Adequate supplies and medication are also
available for planned use and emergency situations. Each organisation understands the required or
recommended equipment, supplies and medications necessary to provide anaesthesia services to its
patient population. Recommendations on equipment, supplies and medication can come from a
government agency, national or international anaesthesia professional or other authoritative sources.
There is an equipment maintenance programme.
40.17.4 Criteria
40.17.4.1. The provision and use of anaesthetic mixture components complies with the guidelines for practice of
the professional society.
40.17.4.2. The provision and use of breathing circuits complies with the guidelines for practice of the
40.17.4.3. The provision and use of ancillary equipment complies with the guidelines for practice of the

40.17.4.4. The provision and use of monitoring equipment complies with the guidelines for practice of the
40.17.4.5. Recommended medications are used.
40.17.4.6. A drug trolley is available for the exclusive use of the anaesthesiologist in each theatre.
40.17.4.7. Theatre staff ensure that all equipment is included in the organisation's equipment replacement and
maintenance programme.
40.17.5. Emergency and protective equipment are provided in the treatment unit.
Intent of 40.17.5
Electro-convulsive therapy staff must prepare for any emergencies through the provision of
emergency and protective equipment.
40.17.5 Criteria
40.17.5.1. Emergency resuscitation equipment is available.
40.17.5.2. Emergency resuscitation equipment shows evidence of regular checking.
40.17.5.3. Emergency and resuscitation equipment and supplies have clearly defined instructions for use.
40.17.5.4. Hazard or warning notices are displayed.
40.17.5.5. Where resuscitation or critical monitoring equipment is used that does not have built-in battery backup
units, there is an uninterruptible power supply (UPS) that complies with relevant requirements and
regularly serviced and tested.
40.17.5.6. There is a mechanism for summoning assistance
40.17.5.7. There is appropriate protective clothing available.
40.17.6. Recovery room facilities and equipment are available to provide safe and
effective care.
Intent of 40.17.6
The number of beds/trolley spaces in the recovery room provides sufficient space for at least one
patient from each ECT treatment room that it services.The provision, use and maintenance of recovery
room equipment comply with the guidelines for practice of the professional society.
40.17.6 Criteria
40.17.6.1. The recovery area forms part of the ECT suite.
40.17.6.2. There are an adequate number of recovery beds for the patients.
40.17.6.4. The provision, use and maintenance of recovery room equipment comply with the guidelines for
practice of the relevant professional society.
40.17.7. Policies and procedures are developed relating to the activities in the
electro-convulsive therapy treatment room.
Intent of 40.17.7
Policies and procedures are necessary to guide the administration of the ECT service to ensure the
smooth operation of the service, and to ensure that staff act swiftly and in a co-ordinated manner in an
emergency. These are made available to all unit, recovery room and anaesthetic staff, and are known
and implemented. Biohazards which need to be monitored and notified include electrical hazards.
40.17.7 Criteria
40.17.7.1. There are written policies and procedures to guide the activities of the ECT treatment room.

40.17.7.2. Policies and procedures relate to the duties of ECT treatment room nursing staff.
40.17.7.3. Policies and procedures relate to ECT treatment room cleaning.
40.17.7.4. Policies and procedures relate to notification of biohazards.
40.17.7.5. Policies and procedures relate to drug control.
40.17.7.6. Policies and procedures relate to patient positioning.
40.17.8. Policies and procedures are developed relating to the preparation of

patients for electro-convulsive therapy.
Intent of 40.17.8
Policies and procedures are available to ensure that informed consent is documented and the correct
patient is identified. Processes during ECT are documented to ensure co-ordination and safety.
40.17.8 Criteria
40.17.8.1. Policies and procedures relating to the preparation of patients for ECT include scheduling of patients
for ECT procedures.
40.17.8.2. Policies and procedures relating to the preparation of patients for ECT include patient identification.
40.17.8.3. Policies and procedures relating to the preparation of patients for ECT include verification of the
treatment.
40.17.8.4. Policies and procedures relating to the preparation of patients for ECT include verification of the last
oral intake.
40.17.8.5. Policies and procedures relating to the preparation of patients for ECT include checking of consent
documents.
40.17.8.6. Policies and procedures relating to the preparation of patients for ECT include equipment required.
40.17.9. Policies and procedures are developed relating to the anaesthetic service.
Intent of 40.17.9
Guidelines of professional societies and associations are available and followed wherever
anaesthesia is administered. This includes nursing staff who assist the anaesthetist and who monitor
the recovery of patients. Implementing these guidelines is particularly important with regard to the
qualifications, training and experience required by staff members in the service, and also the provision,
maintenance and use of medical equipment and drugs.
Controlling bodies also develop guidelines and regulations relating to professional practice.
40.17.9 Criteria
40.17.9.1. Policies and procedures relating to the anaesthetic service include qualifications of persons who
administer anaesthetics.
40.17.9.2. Policies and procedures relating to the anaesthetic service include anaesthetic equipment hazards.
40.17.9.3. Policies and procedures relating to the anaesthetic service include assessing the fitness of patients to
leave the recovery area.
40.17.9.4. Policies and procedures comply with current guidelines of the professional society of
anaesthesiologists.
40.17.10. Pre-anaesthesia assessment is conducted and recorded.

Intent of 40.17.10
Because anaesthesia carries a high level of risk, its administration is carefully planned. The patient's
pre-anaesthesia assessment is the basis for that plan. The pre-anaesthesia assessment provides
information needed to :
• select the anaesthesia and plan anaesthesia care;
• identify any drug sensitivities;

• safely administer an appropriate anaesthetic; and

• interpret findings of patient monitoring.
An anaesthesiologist conducts the pre-anaesthesia assessment.
Anaesthesia care is carefully planned and documented in the anaesthesia record. The plan considers
information from other patient assessments and identifies the anaesthesia to be used, the method of
administration, other medication and fluids, monitoring procedures, and anticipated post-anaesthesia
care.
The anaesthesia planning process includes education of the patient and his or her family or decision-
maker on the risks, potential complications, and options related to the planned anaesthesia and
postoperative analgesia. This discussion occurs as part of the process to obtain consent for
anaesthesia. The anaesthesiologist or the qualified individual who will administer anaesthesia
provides this education.
40.17.10 Criteria
40.17.10. Patients have an anaesthetic assessment performed before surgery or any invasive procedure e.g.
1. bone marrow aspiration, lumbar puncture etc. under anaesthesic.
40.17.10. A qualified individual conducts the pre-anaesthesia assessment of each patient.
2.
40.17.10. The medical assessment of patients for ECT is documented before anaesthesia.
3.
40.17.10. The anaesthesia assessment determines if the patient is an appropriate candidate for the planned
4. anaesthesia.
40.17.10. The anaesthesia assessment identifies any drug sensitivities.
5.
40.17.10. Patients are re-evaluated before the induction of anaesthesia.
6.
40.17.10. The anaesthesia care of each patient is planned.
7.
40.17.10. The plan is documented.
8.
40.17.10. The patient, family and decision-makers are educated on the risks, potential complications and
9. options of anaesthesia.
40.17.10. The anaesthesiologist or other qualified individual provides the education.
10.
40.17.11. Each patient's physiological status is monitored during anaesthesia and

recorded.
Intent of 40.17.11
The anaesthetist monitors and records the physiological status of the patient during anaesthesia, and
enters the drugs and intravenous fluids used, and the anaesthetic, in the patient's anaesthesia record.
The anaesthetist has access to the patient care notes, and is familiarised with the findings of the
medical examination. It is important that each health professional has access to the records of other
care providers, in accordance with organisation policy.
40.17.11 Criteria
40.17.11. The patient's physiological status is continuously monitored during anaesthesia.
1.
40.17.11. The results of monitoring are entered into the patient's record.
2.
40.17.11. The anaesthesia used is entered into the patient's anaesthesia record.
3.

40.17.11. Patient care notes are available to the anaesthesiologist.

4.
40.17.12. There is a system to monitor and document each patient's post-

anaesthesia status, and to discharge the patient from the recovery area according to
accepted guidelines.
Intent of 40.17.12
Physiological monitoring provides reliable information about the patient's status during the
administration of anaesthesia and the recovery period. Monitoring methods depend on the patient's
pre-anaesthesia status, anaesthesia choice, and complexity of the procedure performed during
anaesthesia. In all cases, however, the monitoring process is continuous, and the results are entered
into the patient's record.
Monitoring during anaesthesia provides the basis for monitoring during the post-anaesthesia recovery
period. The ongoing, systematic collection and analysis of data on the patient's status in recovery may
support decisions about moving the patient to other settings and less intensive services. Only a
suitably qualified and experienced registered nurse or designated medical staff may carry out
monitoring in the recovery area. Recording of monitoring data provides the documentation to support
discharge decisions.
The anaesthetist decides whether the patient can be discharged from the recovery area to another
level of care or from the organisation (as in the case of ambulatory anaesthesia). Standardised criteria
developed by medical staff are used to make discharge decisions. The decision to discharge the
patient from the recovery area is recorded in the patient's record. The time of arrival and discharge
from the recovery area are recorded. Signatures of those who handed over and those who received
the patient are recorded.
40.17.12 Criteria
40.17.12. The anaesthetist is responsible for supervising the recovery period.
1.
40.17.12. Patients receive monitoring appropriate to their condition during the post- anaesthesia recovery
2. period.
40.17.12. The qualifications and experience of staff members who may monitor patients are documented.
3.
40.17.12. Monitoring findings are entered into the patient's record.
4.
40.17.12. Established criteria are used to make discharge decisions from the recovery room.
5.
40.17.12. The anaesthetist applies the criteria and discharges the patient.
6.
40.17.12. The anaesthetist signs the patient out of the recovery area.
7.
40.17.12. Recovery area arrival and discharge times are recorded.
8.
40.17.12. Signatures of those handing over and those receiving the patient are recorded.
9.
40.18. Forensic service


Intent of 40.18.1
it.
40.18.1 Criteria
programme.
as appropriate.
40.18.2 Criteria
Intent of 40.18.3
initiation of the care process. Patients' social, cultural and family status are important factors that can
influence their response to illness and care. Families can be of considerable help in these areas of

assessment. A functional and nutritional assessment allows for the patient to be referred for specialist
care if necessary.
Certain patients may require a modified assessment, eg patients suspected of drug and/or alcohol
appropriate.
The outcome from the patient's initial assessment is an understanding of the patient's medical, nursing
and therapeutic needs so that care and treatment can begin.
40.18.3 Criteria
40.18.3.3. The initial assessment includes history of previous head injury.
40.18.3.4. The initial assessment includes drug history.
40.18.3.8. The initial assessment includes psychological assessment. should the patient's condition warrant it.
0.
40.18.3.1 The initial assessment results in an understanding of the care the patient is seeking.
1.
2.
3.
4. needs.
6.
7.
8.

Intent of 40.18.4
needs.
40.18.4 Criteria

40.18.5. Policies and procedures guide the care of forensic patients and the
provision of forensic services.
40.18.5 Criteria
40.18.5.1. Policies and procedures guide access control into the forensic unit.
40.18.5.2. Policies and procedures guide access control within the forensic unit.
40.18.5.3. Policies and procedures guide the control of keys.
40.18.5.4. Policies and procedures guide patients absconding from the forensic unit.
40.18.5.5. Policies and procedures guide managing the violent patient.
40.18.5.6. Policies and procedures guide managing mass violence in the unit.
40.18.5.7. Policies and procedures guide photographs or other artistic reproduction.
40.18.5.8. Policies and procedures guide the transfer of patients from the forensic service.
40.18.5.9. Policies and procedures guide the referral of patient to other health workers/organizations.
40.18.5.1 Policies and procedures guide the discharge of patients from the forensic service.
0.
40.18.5.1 Policies and procedures guide the granting of patients leave from the forensic service.
1.
40.18.5.1 Patients receive care consistent with the policies and procedures.
2.
40.18.6. There are mechanisms designed to facilitate communication and resolve

conflict between judicial, correctional, penal, clinical and administrative agencies and
those involved in an individual's care.
Intent of 40.18.6
Non-clinical constraints can affect admission, treatment and discharge decisions in organizations
providing forensic services. When conflict with security and individual needs occur, staff develop an
adapted plan to simulate normalized experiences.
40.18.6 Criteria
with clinical decisions related to use of seclusion and restraint for nonclinical purposes.
with clinical decisions related to imposition of disciplinary restrictions.
with clinical decisions related to length of stay.
with clinical decisions related to restriction of rights.
with clinical decisions related to plan for discharge and continuing care.


41.Medical Oncology
Overview of Medical Oncology

The healthcare organisation's main purpose is patient care. Providing the most appropriate setting
that supports and responds to each patient's unique needs requires a high level of planning and co-
ordination.
Certain activities are basic to patient care, including planning and delivering care to each, monitoring
the patient to understand the results of the care, modifying care when and completing the follow-up.
Many medical, nursing, radiation therapy, pharmaceutical, rehabilitation and other types of health care
may carry out these activities. Each provider has a clear role in patient care. Credentialing,
registration, law and regulation, an individual's particular skills, knowledge and experience, and
organisational policies or job descriptions determine that patient, the family or trained caregivers may
carry out some of this care.
A plan for each patient is based on an assessment of needs. That care may be preventive, curative or
rehabilitative and may include the use of anesthesia, surgery, radiation, medical (including
chemotherapy) supportive therapies, or a combination of these. A plan of care is not to achieve optimal
outcomes unless the delivery of the services is co-ordinated, and monitored.
Continuity of care
organisation and to other organisations.

Standards

patient's care.
Intent of 41.1.1
41.1.1 Criteria
other staff.

providers.
Intent of 41.1.2
integrate and co-ordinate care for their patients (for example, team-delivered care, multi--departmental
patient care rounds, combined care planning forums, integrated patient records, case managers). The
41.1.2 Criteria

Intent of 41.2.1
provided.

41.2.1 Criteria
ongoing care.
assessments.
unwanted variation.
Intent of 41.2.2
organisation leaders and clinical practitioners before implementation. This ensures that they meet the
criteria established by the leaders and are adapted to the community, patient needs and organisation
resources. Once implemented, guidelines are reviewed on a regular basis to ensure their continued
relevance.
41.2.2 Criteria
41.2.2.1. Organisational and clinical leaders set criteria to select clinical practice guidelines, including
chemotherapeutic and radiation guidelines.

Intent of 41.2.3
41.2.3 Criteria
41.2.3.1. Written. procedures ensure that assessments are performed within appropriate time frames and that
41.2.3.5. Any significant changes in the patient's condition since the initial assessment are noted in the
patient's record.

Intent of 41.2.4
The initial assessment of a patient is critical for the identification of the needs oft tbe patient and
Patients' social, cultural and family status are important to highlight factors that can influence their
or a portion on of the care.
necessary.
Certain patients may require a modified assessment, eg very young patients, the frail or the elderly,
those terminally ill or in pain, patients suspected of drug and/or alcohol dependency. The assessment
process is modified in accordance with local laws and regulations, the culture of the patient population,
and involves the family when appropriate. The outcome from the patient's initial assessment is an
understanding of the patient's oncological and nursing needs so that care and treatment can begin.
When the oncology assessment was conducted outside the organisation, a legible copy is placed in
the patient's record. Any significant changes in the patient's condition since the assessment are
recorded.
41.2.4 Criteria
41.2.4.9. The initial assessment results in the identification of the patient's oncological and nursing needs.

Intent of 41.2.5
The preoperative anesthesia assessment determines if the patient is a good candidate for the planned
surgery and may significantly influence the pre- and intra-operative management. The clinical
In an emergency, the initial medical and oncological assessment may be limited to the patient's
apparent needs and condition.
41.2.5 Criteria
marrow aspiration, lumbar puncture etc. under anaesthetic.

41.2.5.2. The initial medical assessment of patients is documented before anesthesia.

41.2.5.3. Patients have the results of diagnostic tests recorded before anesthesia.
41.2.5.4. Patients have a preoperative diagnosis recorded before anesthesia.
policy.

Intent of 41.2.6
41.2.6 Criteria
patient's care.
41.3. Patient care

41.3.1. Adequate resources are available for the provision of safe care to patients.
Intent of 41.3.1
oxygen and suction are in place and are working satisfactorily. Each bed is serviced by at least one
power supply. .
• Defibrillator with adult and infant (where applicable) paddles
• ECG monitor
• CPR board

• Suction
• Oral airways
The resuscitation equipment is available in adult and pediatric (where applicable) sizes.
• appropriate facilities for intravenous therapy and drug administration (including pediatric sizes
where applicable);
• drugs for cardiac and respiratory arrest, coma, fits and states of shock (including paediatric
doses where applicable);
41.3.1 Criteria
record.
Intent of 41.3.2

41.3.2 Criteria



Intent of 41.3.3

• communicate with, and provide education for, patients and families about pain management in
the context of their personal, cultural and religious beliefs, and
comfort and dignity guides all aspects of care during the final stages of life. To accomplish this, all staff
are made aware of the unique needs of patients at the end of life. These needs include treatment of
primary and secondary symptoms; pain management; response to the psychological, social,
emotional, religious and cultural concerns of the patient and family; and involvement in care decisions.
41.3.3 Criteria
management of pain.
pain management.
Intent of 41.3.4
A variety of services are considered "high-risk" because of tile complex equipment needed to treat a
life-threatening condition, the nature of the treatment or the potential for harm to the patient. In
oncology the administration of both radiation and chemotherapy are considered high risk services.


41.3.4 Criteria
41.3.4.4. Policies and procedures guide the handling of chemotherapy and the prescribing of chemotherapy.
damaged container.)
41.3.4.6. Policies and procedures guide the care of patients with infectious diseases eg. HIV,TB, resistant
staphylococcal infections.
41.3.4.7. Policies and procedures guide the care of immuno-suppressed patients with cancer.
41.3.4.8. Policies and procedures guide the care of patients with oncological emergencies, eg. spinal
compression, neutropenic fever, raised intracranial pressure, hypercalcaemia, tumorlysis syndrome,
superior vena cava syndrome.
41.3.4.10. Policies and procedures guide the care of frail, or terminal patients.
Intent of 41.3.5
consent and how they can give consent, for example, by signing a consent form, or through some
other mechanism. Patients and families understand who may, in addition to the patient, give consent.
Designated staff are trained to inform patients and to obtain and document patient consent. These staff
members clearly explain any proposed treatments or procedures to the patient and, when appropriate,
the family. Informed consent includes:
• an explanation of the risks and benefits of the planned procedure or treatment.

In addition, when chemotherapy, radiation and blood or blood products may be needed, information on
the risks and alternatives are discussed.
The organisation lists all those procedures which require written, informed consent. Leaders document

the processes for the obtaining of informed consent.

documentation of the patient's consent in the patient's record by the individual who provided the
understanding ofthe information. The patient's surgeon or other qualified individual provides the
41.3.5 Criteria
41.3.5.13. The education includes the need for, risk of, and alternatives to chemotherapy, radiation, blood and
blood product use.
consent.
41.4. Medication and chemotherapy

41.4.1. Medication and chemotherapy use in the organisation complies with
applicable laws and regulations.
Intent of 41.4.1
Medication and chemotherapy management is not only the responsibility of the pharmaceutical
service, but also of managers and clinical care providers. Medical, nursing, pharmacy and
administrative staff participate in a collaborative process to develop and monitor policies and
procedures.
Each organisation bas a responsibility to identify those individuals with the requisite knowledge and
experience, and who are permitted by law, registration or regulations to prescribe or order medications
or and chemotherapy. In emergency situations, the organisation identifies any additional individuals
permitted to prescribe or order medications (inclusive of anti-nausea drugs and analgesics).
Requirements for the documentation of medications ordered or prescribed and for the use of verbal
medication orders are defined in policy. Medications brought into the organisation by the patient or his
or her family are known to the patient's physician and are noted in the patient's record.
41.4.1 Criteria
41.4.1.1. Policies and procedures guide the safe prescribing, ordering and administration of medications and/or
chemotherapy in the patient care unit.

individuals.
41.4.1.7. Medications and chemotherapy brought into the organisation by the patient or his or her family are
known to the patient's physician and are noted in the patient's record.
41.4.2. Medications and chemotherapy are safely administered.

Intent of 41.4.2
Only staff who are suitably trained and experienced may administer medication and chemotherapy to
patients. The responsibility of these persons for medication and chemotherapy administration is
documented. The safe administration of medications requires a strict and comprehensive protocol.
Policies for patient preparation and work-up are done prior to each chemotherapy to prevent adverse
events.
medications and chemotherapy. The purposes of monitoring are to evaluate the response to
medication and chemotherapy, adjust the dosage or type of medication/chemotherapy when needed,
and to evaluate the patient for adverse effects.
medication errors through understanding the types of errors that occur. Improvements in
medication/chemotherapy processes and staff training are used to prevent errors in the future. The
pharmacy participates in such staff training.
41.4.2 Criteria
medications/chemotherapy.
41.4.2.2. Medications/chemotherapy are checked against the original prescriptions and administered as
prescribed.
41.4.2.4. Healthcare professionals monitor medication/chemotherapy effects on patients collaboratively.
41.4.2.6. Adverse medication/chemotherapy effects are observed and recorded.
41.4.2.8. Medication/chemotherapy errors are reported through a process and within a time frame defined by
the organisation.
41.4.2.9. The medications/chemotherapy prescribed for and administered to each patient are recorded.
41.4.3. Medications/chemotherapy are stored in a safe and clean environment.

Intent of 41.4.3
Patient care units store medications/chemotherapy in a clean and safe environment that complies with
law, regulation and professional practice standards.
41.4.3 Criteria
41.4.3.1. Medication/chemotherapy is stored in a locked storage devise or cabinet that is accessible only to
authorised staff.
authorised staff have keys.

41.4.3.3. Medications/chemotherapy are legibly marked and securely labelled.

41.4.3.4. Medications/chemotherapy are stored in a clean environment.
41.4.3.5. Medication/chemotherapy is stored in accordance with manufacturer's instructions relating to
temperature, light and humidity.
41.4.3.6. A refrigerator is available for those medications/chemotherapy requiring storage at low temperatures.
date.
41.4.3.10. Chemotherapy preparation must be undertaken with protective gear and in an appropriate
environment to protect the workers against possible adverse effects.

41.5.1. Food, and nutrition therapy appropriate for the patient and consistent with his
Intent of 41.5.1
41.5.1 Criteria

record.
Intent of 41.6.1
Education is focused on the specific knowledge and skins that the patient and his or her family will
Education is provided to support the care decisions of patients and families. In addition, when a patient
or family directly participate in providing care, for example changing dressings, feeding and

41.6.1 Criteria
preferences.
Intent of 41.6.2
organisation selects appropriate educational methods and people to provide the education. Staff
collaboration helps to ensure that the information patients arid families receive is comprehensive,
41.6.2 Criteria

Intent of 41.7.1
41.7.1 Criteria


Intent of 41.7.2
To ensure continuity of care, adequate information must accompany the patient
41.7.2 Criteria
transferred.
organisation.
patient's record.

Intent of 41.7.3
41.7.3 Criteria
41.7.3.6. Patients and their families, as appropriate, are given understandable follow-up instructions by the
medical practitioner in writing the discharge note at referral or discharge.
care.
patient's record.
Intent of 41.7.4

41.7.4 Criteria
41.7.4.1. A discharge summary is written, by the medical practitioner, at the discharge of each patient.

medical service.
Intent of 41.8.1
41.8.1 Criteria
41.8.1.1. There is a written quality improvement programme for the medical oncology service that is developed
and care.
interventions and responses to record incidents.

41.9.1 Criteria

41.9.1.5. The right of a patient to health education is recognised


41.10.1 Criteria
41.10.1.1. There is a programme, which is implemented, to reduce the risks of nosocomial infections inpatients
specimens.
infection control.

41.11.1 Criteria
41.11.1.1. The Health and Safety representative for the service directs the implementation of the health and
safety programme.
41.11.1.3. There is plan to respond to likely community emergencies, and disasters, relating to radiation as well
as chemotherapy and radio-active sources.
and visitors from exposure of radiation and chemotherapeutic drugs.


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BOTSWANA HOSPITAL STANDARDS V2

STANDARDS AND CRITERIA

 STANDARDS ASSESSMENT REFERENCE DOCUMENT

Date generated: 16/03/2010

SE 1 Management and Leadership 5

SE 2 Human Resource Management 15

SE 5 Patient and Family Rights 37

SE 7 Health and Safety 53

SE 8 Quality Management and Improvement 61

SE 9 Prevention and Control of Infections 71

SE 10 Medical/Surgical/Paediatric & Obstetrics 77

SE 12 Surgical Care 109

SE 13 Critical Care 125

SE 14 Obstetric/Maternity Care 139

SE 15 Psychiatric Care (Ward) 155

SE 16 Paediatric Care 171

Diagnostic and treatment support services 187

SE 17 Operating Theatre and Anaesthesia services 187

SE 18 Nuclear Medicine 197

SE 19 Laboratory service 205

SE 20 Radiology service 211

SE 21 Pharmaceutical service 217

Ambulatory care 225

SE 22 Emergency Care 225

SE 23 Outpatient Care 239

SE 24 Ambulatory Care 253

ANCILLARY SERVICES 269

SE 25 Sterilising and Disinfecting Unit 269

SE 26 Food Service 275

SE 27 Laundry Service 281

SE 28 Housekeeping Service 287

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SE 29 Maintenance service 293

SE 30 Resuscitation Service 301

SE 31 Healthcare Technology Management 305

PROFESSIONAL SERVICES 313

SE 32 Physiotherapy Service 313

SE 33 Occupational Therapy Service 319

SE 34 Dietetic Service 325

SE 35 Speech Therapy Service 331

SE 36 Clinical Psychology Service 337

SE 37 Social Work Service 343

SE 39 Dental Service 349

SPECIALISED SERVICES 361

SE 40 Psychiatric Care (Hospital) 361

SE 41 Medical Oncology 403

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HEALTH CARE ORGANISATION MANAGEMENT

1.Management and Leadership

Overview of Management and Leadership

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1.1. Governance of the organisation

1.2. Management of the organisation

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1.2.1. A senior manager is responsible for operating the organisation within

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