Standards, guidelines and policies
The NHMSFAP standards, guidelines and policies represent the minimum level of performance required to achieve accreditation with CPSBC. The public can use these standards to understand CPSBC’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
- Licensee Designate
- New Technology Policy (Including Artificial Intelligence)
- Clinical Research in Non-Hospital Facilities
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
Policies
- Appropriate Surgical Uterine Evacuation Procedures for Non-Hospital Facilities
- Colonoscopy with Polypectomy
- Gluteal Fat Grafting
- Hair Restoration Procedures in Non-Hospital Facilities
- Hernia Procedures in Non-Hospital Facilities
- Laparoscopic Cholecystectomy in Non-Hospital Facilities
- Podiatric Surgeon Procedures – Setting, Imaging, and Room Size Requirements
Position statements
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
Accreditation standards
- Medical Device Reprocessing
- Anesthesia Equipment Reprocessing
- Single-use Devices and Multi-dose Vials
- Hand Hygiene
- Best Practices for 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
- Patient Safety and Incident Management
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
For physicians and surgeons