A surprising amount of surgical risk is decided before anyone picks up an instrument — in how the patient was selected, screened, consented, and assessed. That's why the College of Physicians & Surgeons of Alberta (CPSA) standard devotes a whole section to it: NHS.6.0 — Pre-Service Policies, Processes & Procedures. It's where the Quality Management System meets the patient for the first time, and it covers everything from the request to the moment they're wheeled toward the operating room.
What CPSA expects
The section moves through four stages — the request, preparation and consent, identification, and admission. In plain language:
- Published, accurate service information. The facility makes its services and the relevant requirements easily available — location, hours, booking, current service list, patient education and preparation instructions, the pre-assessment process, after-hours/critical-findings handling, and the confidentiality and complaint policies — and what's published matches what's actually done.
- A complete service request (requisition). Every request carries enough to uniquely identify the patient (name, a second identifier, date of birth) and the authorized requestor, plus the clinical detail needed to perform and interpret the service — with a process to chase missing information before proceeding, a record of every request, and periodic review of the forms.
- Safe handling of verbal requests. Read-back of the full order, written or electronic confirmation within a set time, and full documentation of who, what, and when.
- Scheduling that accounts for the real variables. Staff and equipment availability, patient convenience, infection-control considerations, and medications — with enough time allotted for admission, the service, the operative report, and turnover.
- Preparation and pre-screening matched to complexity. Patients get prep instructions and complete a pre-screening that captures the medication review, relevant history, confirmation they followed instructions, and height/weight — and are told when a responsible adult must accompany them at discharge, with a documented path when one can't be arranged.
- Genuine informed consent. The right professional informs the patient — in writing and in discussion — of the alternatives, the usual and rare complications, the life-threatening ones, the possibility of unplanned transfer to hospital, and the physician's training and experience; the consent form addresses general care and the anesthetic choice alongside procedure- and anesthesia- specific risks; and refusals of advised care are documented with the patient's acknowledgment of the consequences.
- Accept/reject criteria — and what happens when a service can't proceed. Defined criteria for reviewing and accepting or rejecting patients/services, recognition of risk factors and contraindications, and a documented conversation with the requestor about the risks of proceeding versus not when the service can't go ahead as requested.
- Positive patient identification. Identity confirmed before any service using at least two unique identifiers, a process for patients with communication challenges, and identification of those who can't identify themselves (including pediatric patients) by a responsible adult — with services performed only on a valid clinical indication.
- Admission risk assessment and admission assessment. Screening for antibiotic-resistant organisms, illness, and skin infections with notification of the surgeon/anesthesiologist on positive results; and a full admission assessment — two-identifier check, allergies and alert wristband, procedure/site/side verification, consent and fasting status, vital signs, BMI (with anesthesiologist notification at 40+), medication review — reviewed by a regulated health professional, feeding the surgical site marking and the preoperative checklist before transfer to the OR.
Why facilities struggle with it
- Consent is a signature, not a conversation. The form gets signed, but the discussion of alternatives, rare-but-serious complications, and the chance of hospital transfer isn't evidenced.
- Requisitions arrive incomplete and get worked anyway, with no process to chase the missing identifier or clinical detail first.
- Screening is informal. ARO/illness screening and the admission assessment happen "in the room" without the structured record the standard expects.
- Two-identifier ID slips under time pressure — the single most preventable safety gap there is.
What "getting it right" looks like
- A consent process that captures the discussion, not just the signature — with the alternatives, the serious risks, and the transfer possibility on the record.
- A requisition gate that won't let an incomplete or unverified request through.
- A structured admission assessment and preoperative checklist, reviewed by a regulated professional, with site marking done to the standard's conditions.
- Two-identifier confirmation enforced at every step, every time.
How Zosimos helps
We help facilities turn the pre-service pathway into a system that's safe and provable: consent and screening processes that capture the evidence, requisition and scheduling workflows that close the gaps, and admission/preoperative checklists built to the standard. Where this lives on paper, the Accreditation Audit Tool and PolicyHUB we're building on the Zosimos Enterprise hub — launching soon — are designed to standardize the forms and keep the completed records retrievable.
For non-surgical clinics: the request, verbal-order, scheduling, consent, two-identifier identification, and valid-indication requirements all transfer directly. The surgical admission pieces — ARO screening, fasting verification, site marking, the full preoperative checklist — mostly become not applicable, though the underlying ideas (allergy alerts, vital signs, medication review at intake) remain good practice.
See our CPSA NHSF accreditation support or get in touch if your consent or admission records wouldn't show the full conversation an assessor looks for. For the bigger picture, start with what a Quality Management System really means.