Navigating the 2026 Department of Health Codes of Practice: What Hong Kong Clinics and Day Procedure Centres Need to Know Before July 2026

Date: 23 June 2026
Author: Rendy Ng & Amber Yung | Rendy Ng Law Firm

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Introduction

The Department of Health has updated the Codes of Practice (“CoP”) for both Clinics (PHF(E) 31A) and Day Procedure Centres (PHF(E) 21A), with the amendments taking effect on 16 July 2026. The updates reflect an enhanced regulatory focus on patient safety during procedural sedation, stricter requirements for infection control, and improved complaint handling mechanisms.

For doctors, clinic owners, and medical directors, understanding these changes before they come into force is not merely a matter of regulatory compliance, it is about safeguarding your practice against potential disciplinary actions and liability. This article distils the key changes introduced by the 2026 CoP updates and translates them into practical steps that your healthcare facility should take now.

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What are the Key Overarching Changes in the 2026 Codes of Practice?

1. New Sedation Framework For Day Procedure Centres

The most significant changes in the 2026 updates concern Day Procedure Centres (“DPCs”), specifically in the area of sedation and anaesthesia. The previous CoP used the generic term “sedation” but the 2026 version introduces a critical distinction between two categories. Conscious (moderate) sedation will be governed by the updated Guidelines on Procedural Sedation (2025) promulgated by the Hong Kong Academy of Medicine (“HKAM”) and deep sedation will be governed by the Recommended Minimum Facilities for Safe Anaesthetic Practice in Anaesthetising Locations Outside Operating Suites (v2, 2024) promulgated by The Hong Kong College of Anaesthesiologists (“HKCA”).

How will the New Sedation Framework Impact DPC Administration and Procedure?

Following the new distinction between conscious (moderate) sedation and deep sedation, the CoP has refined policies on the administration of anaesthetic services. The 2026 update will extend the requirement for an anaesthesiologist to oversee anaesthetic care including not only general anaesthesia, neuroaxial block, and major plexus block, but also deep sedation and the use of potent anaesthetic agents with no specific antagonists (“Anaesthetic Services”).

From 16 July 2026, the administration of these Anaesthetic Services will be restricted to an anaesthesiologist or a trained medical practitioner under the direct supervision of an anaesthesiologist. If said services are undertaken and the Chief Medical Executive (“CME”) is not anaesthesiologist, a specialist in anaesthesiology must be appointed as an advisor to regularly review facilities, equipment, staff training, and procedures related to the anaesthetic service.  

Other major changes impacted by the new sedation framework include emergency medication, equipment, and post-procedural requirements. When selecting emergency medication, deep sedation now requires anaesthesiologist consultation. Facilities are now mandated to have sufficient equipment for patient monitoring under both conscious (moderate) sedation and deep sedation procedures. Patients who have received deep sedation will be required to have a responsible adult to escort them home, aligning the post procedure requirements for deep sedation with those already applicable to general anaesthesia.

These new policies will have significant operational implications. Day Procedure Centres performing deep sedation without an anaesthesiologist must restructure staffing, update procedural protocols, and revise equipment checklists before the effective date. Facilities should consult their anaesthesiologist advisor to review and approve emergency deep sedation medication inventory and ensure proper documentation of these efforts.

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2. New Requirements for Complaint Handling

Both Clinics and Day Procedure Centres CoPs will introduce a new mandatory clause regarding patient complaints (Clause 3.9.3 for Clinics and Clause 1.3.10.3 for DPCs).

From 16 July 2026, healthcare facilities will be required to post a notice detailing the channels for receiving complaints. This notice must be displayed prominently for patients at the admission or reception office, cashier, and other appropriate locations. Importantly, the notice must also include the contact information of the Committee on Complaints against Private Healthcare Facilities. Clinic managers should ensure these notices are drafted and displayed before the effective date to avoid an immediate compliance breach upon the CoP coming into force.

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3. Changes to Infection Control Standards

The infection control standards in both CoPs will be tightened, particularly in relation to the sterilisation of reusable medical equipment. The relevant clauses have been revised to explicitly extend their scope to dental procedures.

From 16 July 2026, reusable equipment and supplies used in invasive procedures involving sterile tissue or the vascular system, or used in dental procedures, will be required to be properly processed and rendered sterile by appropriate sterilisation procedures. Facilities that provide dental services should review their current sterilisation protocols now to ensure full compliance with this expanded requirement.

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4. Mandatory Changes

A major change in the 2026 versions of the Clinics and Day Procedure Centres CoPs is the shift where numerous previously optional or recommended measures are now mandatory. Here is the full list of clauses that are now explicitly mandatory:

1. Chief Medical Executive Accountability (DPCs): The CME must be held accountable for the clinical management of the facility.
2. Medicine and Vaccine Storage (DPCs): The facility must provide medicines and biological products in a safe and effective manner, as well as ensure proper vaccine storage handling.
3. Complaint Handling (DPCs and Clinics): The facility must provide visible public notice of complaint channels, including the Complaint Committee's contact details.
4. Sterilisation of reusable equipment (DPCs and Clinics): Reusable equipment and supplies used in procedures involving sterile tissue or vascular system, or used in dental procedures, must be properly rendered sterile, stored in a clean and dry area, and regularly checked for expiry.
5. Facility Management Doorway Requirements (DPCs): In facilities that handle deep sedation, general anaesthesia or major reginal anaesthesia procedures, doorways in the procedural area must permit trolley or stretcher access.
6. Equipment for Monitoring Sedation (DPCs): Facilities must have sufficient equipment, which includes resuscitation equipment and emergency medication, to monitor patients under conscious (moderate) sedation and deep sedation.
7. Pre-Procedural Assessment Requirements (DPCs): For patients undergoing procedures under conscious (moderate) sedation, general anaesthesia, major anaesthesia or deep sedation, there must be a pre-procedure assessment.
8. Administration of Anaesthesia (DPCs): Anaesthetic Services must only be administered by anaesthesiologists or trained medical practitioners under their direct supervision. If said services are undertaken and the CME is not an anaesthesiologist, a specialist in anaesthesiology must be appointed as an advisor to regularly review facilities, equipment, staff, and anaesthetic procedures.
9. Staffing and Monitoring (DPCs): Staffing arrangements and monitoring of patients undergoing conscious (moderate) sedation or deep sedation must be in accordance with HKAM and HKCA standards.
10. Post-Procedure Recovery (DPCs): Recovery of patients who have received conscious (moderate) sedation, general anaesthesia or major regional anaesthesia must take place in an area that is adequately equipped and staffed for post-anaesthetic care, in accordance with HKAM and HKCA standards.
11. Post-Procedure Discharge Policies (DPCs): The facility must have written policies or procedures for the discharge of patients after sedation or anaesthesia.
12. Post-Procedure Responsible Adult Escort (DPCs): For a patient who has received anaesthesia or sedation, a responsible adult must escort them home.
13. Records of Anaesthetic/Sedation Care (DPCs): Deep sedation, conscious (moderate) sedation, and anaesthesia require full records per HKCA standards.
14. Emergency Mediation Selection (DPCs): Selection of medications to deal with emergency arising from anaesthesia or deep sedation must be in consultation with an anaesthesiologist.

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Strategic Takeaways for Medical Practitioners and Clinic Owners

Here are the key compliance steps for medical practitioners and clinic owners ahead of the 2026 Code of Practice taking effect on 16 July 2026:

• Audit Your Sedation Protocols: If your Day Procedure Centre performs sedation, audit your protocols to ensure they distinguish between conscious (moderate) sedation and deep sedation, and that staff credentialing, equipment, and pre-procedural assessment processes align with the new HKAM and HKCA guidelines respectively.
• Update Patient Complaint Notices: Draft and display notices regarding complaint channels and the contact information for the Complaints Committee at your reception and cashier areas before the effective date.
• Review Infection Control for Dental Services: Verify that your sterilisation processes, particularly for dental equipment, will meet the explicit requirements of the 2026 CoP.
• Review Anaesthetic Staffing Arrangements: Ensure that any deep sedation procedures will be conducted under the supervision of a specialist in anaesthesiology, and that your anaesthetic advisory arrangements cover the broader scope now required.
• Treat the CoP as Mandatory Rules: The shift to mandatory (“must”) language means that the CoP is no longer a set of aspirational standards. Documentation of your compliance efforts will be your primary legal defence in the event of a Department of Health inspection or disciplinary inquiry.

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Disclaimer: Nothing herein shall be interpreted as legal advice to any person. Readers are encouraged to consult their legal representatives for independent advice. The information provided is based on overall observations and the experience of the practitioners of the firm at the time of writing. The content may change without prior notification depending on changes in the law. If there are two versions of the article in different languages, the English version will prevail in case of discrepancies.

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