Existing facilities

The NHMSFAP awards accreditation to facilities for a period of up to five years.

Existing facilities must undergo a reaccreditation assessment at four years and correct any non-conformances to ensure compliance with standards before the award expires.

Addition or expansion of services

Facilities must make an application to the NHMSFAP Committee to:

  • add any medical, surgical, dental or anesthesia procedures
  • add programs not currently performed at the facility
  • expand an existing medical-surgical program

Application form to make changes

The medical director must do the following when planning for the addition or expansion of services:

  • conduct a thorough clinical evaluation of the facility
  • provide evidence that the facility can provide a safe environment to ensure quality patient outcomes

Addition of New Program, Additional Procedures or New Contracts policy

X-ray or laser equipment

Facilities considering adding X-ray or laser equipment must contact the NHMSFAP.

The following may be required for facilities planning to add X-ray or laser equipment:

  • an on-site assessment to confirm NHMSFAP standards for laser safety and X-ray and radiation safety are in place
  • submission of the appropriate laser notification form and an X-ray notification form for each piece of laser and X-ray equipment on site

Laser Safety standard

Laser Equipment Notification

X-ray and Radiation Safety standard

X-ray Equipment Notification

NHMSFAP standards, guidelines and policiesarrow_right_alt
Learn more about CPSBC’s expectations of accredited private medical/surgical facilities
Credentialing and privilegingarrow_right_alt
Learn more about the appointment process required for all medical staff in facilities
Forms for new and existing facilitiesarrow_right_alt
Apply and notify the NHMSFAP of administrative and operational changes

Report a patient safety incident

Protecting patient safety is the NHMSFAP’s top priority.

The medical director must provide written notice of patient safety incidents to the registrar in accordance with the patient safety incident management standard.

Report the patient safety incident