Stage one reviews your policies and procedures for management and clinical systems off site, alongside prior certification and contract audits, before anyone visits. The Ministry's sector guidance then points to the documents most criteria rely on, from the complaints register to the quality plan, and it is guidance only, never audited against.
What stage one reads
Every certification audit starts with a document review off site, covering policies and procedures and any prior certification and contract audits supplied by a public hospital or Disability Services.1 The agency sends written findings at least one week before stage two, saying whether each document is present and current with Ngā Paerewa, so minor gaps can be fixed before the visit. Documents can be supplied electronically.1
The documents most criteria rely on
| Area | What to have | Subsection |
|---|---|---|
| Complaints | A policy and procedure, information on how to complain, and an up-to-date register with actions | 1.8 |
| Communication | Information in formats and languages people understand, and access to interpreters | 1.6 |
| Quality and risk | An annual quality plan reviewed quarterly, an internal audit programme and a risk assessment | 2.2 |
| Adverse events | A process aligned with the national adverse events policy | 2.2 |
| Information | An overarching information management policy, and records signed and dated | 2.5 |
| Infection prevention | The programme and its implementation | 5.2 |
| Facility | A building warrant of fitness and an approved evacuation scheme | 4.1 and 4.2 |
The table draws on the Ministry's sector guidance, which interprets each criterion for different service types.2 The facility documents are the ones the handbook names for partial provisional and certification audits.1
- Build a document register. Every policy and procedure, with its owner, version and review date.
- Map each to a subsection. So the stage one reviewer can see which criteria each document supports.
- Read the sector guidance. For your service type, as a guide to what good looks like, knowing it is not audited against.
- Test each against practice. Ask staff on each shift where a procedure lives and what it says.
- Send the set to your agency. Electronically, in time for stage one findings a week before the visit.
- Document ______ Version ______
- Subsection it supports ______
- Owner ______ Approved by ______
- Last reviewed on ______ Next review on ______
- Staff told on ______ Where staff find it ______
Records count as documents too
The sector guidance asks for records that are uniquely identifiable, legible, timely, signed and dated, with the name and designation of the person who wrote them, and written in partnership with the person where possible.2 People can request and review their own records, in a format accessible to them.2
Questions
Is the sector guidance mandatory?
No, the Ministry says it is a guide, is not mandatory and is not audited against. It shows ways to meet each criterion.
When does the agency review our documents?
At stage one, off site, before the on-site audit, with written findings at least one week before stage two.
Can we send documents electronically?
Yes, the handbook says stage one documents can be supplied or accessed electronically.
Sources
- 1Ministry of Health, 2025Designated Auditing Agency Handbook, Ministry of Health Auditor Handbook (revised 2025)Read source
- 2Ministry of Health, 2021Sector Guidance for Ngā Paerewa Health and Disability Services Standard (NZS 8134:2021)Read source
Written by the wai team from HealthCERT, Ministry of Health guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither HealthCERT nor the Ministry of Health endorses wai or any software.