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
  • enter into a new contract with a health authority or other third party

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 registration form

X-ray and Radiation Safety standard

X-ray notification form

Learn more about the College’s expectations of accredited private medical/surgical facilities
Learn more about the appointment process required for all medical staff in accredited non-hospital...
Apply and notify the NHMSFAP of administrative and operational changes

Report a patient safety incident

Protecting patient safety is the NHMSFAP’s top priority.

A medical director must notify the program within one working day after the discovery of a reportable incident at their facility.