Non-Hospital Medical and Surgical Facilities Accreditation Program

Acting in the public interest, the NHMSFAP accredits private medical and surgical facilities in BC. The program sets accreditation standards and guidelines to ensure the delivery of high-quality health services.

Ensuring the safety, quality and consistency of patient care in private medical/surgical facilities in BC

Only accredited facilities are permitted to provide patient care

Non-hospital facilities provide surgical and procedural care in the community setting. They are often referred to as private facilities.

The role of the NHMSFAP is to assess these facilities to ensure they maintain recognized standards of practice for the delivery of safe and quality patient care. Facilities must meet these standards to be awarded a term of accreditation. Only facilities accredited by the NHMSFAP are permitted to provide patient care in British Columbia.

All medical staff must undergo an appointment process

All medical staff in accredited non-hospital facilities in BC must undergo an appointment process. Privileges at a non-hospital facility are requested through the facility’s medical director. The NHMSFAP reviews and verifies the scope of practice for the privileges granted by the facility medical director.

The NHMSFAP Committee has adopted the BC MQI dictionaries as objective criteria for core, non-core, training, and experience requirements within each specialty.

Developing standards that ensure safety and quality of care at non-hospital medical and surgical facilities

NHMSFAP standards are the level of performance expected by the College of all private medical/surgical facilities that perform procedures restricted to accredited facilities. The standards are used to evaluate the safety and quality of care delivered in these facilities.

The accreditation standards focus on important patient care practices and organizational functions that are essential to safe and quality care. This includes:

  • clinical care processes
  • medication safety
  • infection prevention and control

NHMSFAP standards are developed using a defined and rigorous process. This process reflects best practice guidelines established by international evaluation organizations that assess accreditation programs and standards.

Non-Hospital Medical and Surgical Facilities Accreditation Program Committee

The NHMSFAP Committee determines if a facility should be accredited and the type of accreditation it should be awarded. The committee reports to the College’s Board. Its members include physicians, surgeons, and public representatives.  

Its responsibilities are spelled out in the College Bylaws. The Bylaws state the committee must ensure the delivery of high-quality and safe services by establishing:

  • accreditation standards
  • policies
  • rules
  • procedures  
  • guidelines

The committee may appoint advisors or groups to assist with responsibilities such as the revision of standards or guidelines. The committee also receives patient safety incident reports from accredited facilities. If necessary, the committee will make recommendations or give direction to those facilities to improve care. 

Getting accredited, credentialed and privileged

Access standards, policies, guidelines and forms for accredited non-hospital facilities and physicians seeking to be credentialed and privileged in a non-hospital facility.

NHMSFAP standards, guidelines, and policies
All medical staff in accredited non-hospital facilities in BC must undergo an appointment process
Facilities and physicians in community-based physician offices who perform procedural pain...
Read the College's requirements for reprocessing ultrasound probes

Facility accreditation

Requirements for pre-construction, construction, post-construction, and renovation
Accreditation, changes to the facility, adding a service or program, clinical trials

Report a patient safety incident

Protecting patient safety is the NHMSFAP’s top priority.

A medical director must complete and submit the form below within 24 hours of being aware of a patient safety incident or death at their facility.