Standards, guidelines and policies
The NHMSFAP standards, guidelines and policies represent the minimum level of performance required to achieve accreditation with the College. The 17³Ô¹Ï can use these standards to understand the College’s expectations of accredited private medical/surgical facilities.
Facilities management
Accreditation standards
- Governance and Leadership
- Medical Director
- Quality Performance
- Human Resources
- Indigenous Cultural Safety, Cultural Humility and Anti-racism
Policies
- Levels of Accreditation
- Terms of Accreditation
- Addition of New Programs, Additional Procedures or New Contracts
- Appointment of Medical Staff to Facilities
- Emergency Training Requirements
- Requirement for Continuity of Care
- Registrant Designate
Position statements
Patient experience
Accreditation standards
Procedure specific
Accreditation standards
- Immediately Sequential Bilateral Cataract and Immediately Sequential Bilateral Refractive Lens Exchange Surgery
- Intravenous Use of Ketamine for the Treatment of Mood Disorders
- Ketamine and Lidocaine Infusions for the Treatment of Chronic Pain
- Laparoscopic Adjustable Gastric Banding
Position statements
- Colonoscopy with Polypectomy
- Gluteal Fat Grafting
- Inhalational Sedation and Analgesia
- Hair Restoration Procedures
Policies
Building services
Accreditation standards
- Accessibility, Operations and Maintenance
- Electrical Systems and Safety
- Heating, Ventilation and Air Conditioning (HVAC)
- Medical Gas – Pipeline System
- Medical Gas – Free-standing Tank System
Policies
- Acquisition and Installation of New Fixed Equipment or Replacement of Current Fixed Equipment
- Construction and/or Renovation Time Limit
- Facility Design Assessment
- Interdisciplinary Design Team Membership
- Major Renovations for Reasons of Maintenance or Restoration
- New Facility Application Fee
- Renovations and New Construction to a Facility
Emergency preparedness
Accreditation standards
- Emergency Preparedness
- Emergency Cart Medication and Equipment
- Malignant Hyperthermia
Policies
Videos
- Emergency Preparedness and Emergency Carts
Infection prevention and control
Standards
- – Ministry of Health (BC)
- Anesthesia Equipment Reprocessing
- Single-use Devices and Multi-dose Vials
- Hand Hygiene
- – Ministry of Health (BC)
- Reprocessing Requirements for Ultrasound Probes
- Routine Practices and Additional Precautions
- Environmental Cleaning Program and Non-Clinical Areas
- Environmental Cleaning of Operating/Procedure Rooms and Sterile Core
- Environmental Cleaning of Pre- and Post-Anesthesia Care Areas
- Environmental Cleaning of the Medical Device Reprocessing Department
- Waste Management
- Surgical Site Infection Surveillance
- Infection Prevention and Control Program
Policies
Safety and risk
Accreditation standards
- Surgical Safety Checklist
- Surgical Safety Checklist Template (MS Word)
- Specimen Handling
- Medication Management
- Latex Allergy
- Point-of-Care Testing
- Equipment Management
- Occupational Health and Safety
- Fluid and Blanket Warming
- Allografts
- Blood Products and Blood Components
- Laser Safety
- X-ray and Radiation Safety
- Food Safety
Guidelines
- ASA Physical Status Classification
- Fasting
- Obesity
- Pediatric Obesity
- Obesity and In Vitro Fertilization Procedures
Position statements
Policies
Videos
- Glucose Meters and Quality Control Testing
Procedural pain management
Accreditation standards
Reserved for accreditation programs web account access only
Part 5, Section A
For physicians and surgeons