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Standards › Standard 2B › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · ACC-SOP-001 · Version 1.1 · Approved by the ASF Expert Committee

Supports: 2B.2

At a glance

  • Give every arrival a number for registration and triage, in the order of arrival, except for clinical priority.
  • Post the expected wait at the desk and update it at least every 30 minutes.
  • Call patients by number, with a second check if a patient does not come.
  • Record arrival and seen times for every patient in the queue log.
  • Review waits each month and act where they exceed the target.
  • Stop and get help straight away if: a patient has waited beyond the target without an update, or a clinically urgent patient is waiting for the queue.

1. Purpose

To make waiting for registration, triage or an appointment fair, visible and predictable, so patients know how long they will wait and are not forgotten [EC].

2. Scope

Applies to Reception, registration, triage and ambulatory appointment staff
Locations Registration, triage and waiting areas at the facility
When From arrival until the patient is registered, triaged or seen
Does not apply to Emergency arrivals, who are seen according to the triage SOP (SOP-077)

3. Definitions

Term Meaning
Queue number The number given to a patient on arrival
Expected wait The time the team estimates the patient will wait, shown on the information board
Wait target The maximum time set by the committee for each step (EC)

4. Background

Patients who do not know how long they will wait feel forgotten, and this increases stress and complaints. A visible queue with honest information reduces both, and the queue log shows actual waits for the review.

5. Responsibilities

Role Responsibility Competence
Reception lead Runs the queue; updates the board; reviews the log monthly Reception management
Reception and triage staff Call patients in order; record times; update the board Induction
Service heads Review waits in their service and act on delays Management training

6. Materials and equipment

Item Requirement Condition
Numbering system Printed numbers or electronic queue Working; clear numbers
Wait information board Shows current number and expected wait Updated at least every 30 minutes
Queue log (ACC-FRM-001) Current Available at the desk

7. Safety

8. Before you start

9. Procedure

Step 1. Give a number on arrival.

  • Give each patient a number in order of arrival.
  • Ask the patient if they have any urgent symptom; triage them at once if so.
  • Tell the patient the expected wait.

Key point: Asking about urgency at the door catches the people who should not wait.

Step 2. Update the board.

  • Show the current number being called and the expected wait.
  • Update at least every 30 minutes, and whenever the wait changes by more than 10 minutes (EC).

Key point: An honest wait is more useful than a fast promise.

Step 3. Call patients in order.

  • Call the next number clearly.
  • If the patient does not come within 2 minutes, call again, then move to the next and return them to the queue at the next open place (EC).

Key point: A clear call prevents people being missed.

Step 4. Record the times.

  • For each patient, record arrival time, call time and seen time on ACC-FRM-001.

Key point: Times are the only way to see whether the queue is working.

Step 5. Review monthly.

  • Calculate the median and the 90th percentile wait for each step each month.
  • Compare with the target and report to the reception lead.
  • Act on any step where the target is missed for two months.

Key point: Averages hide the long waits. Look at the 90th percentile.

10. Decision points

11. Special situations

Situation Action
Child or older patient waiting Check at each board update and offer a seat or priority where needed (EC).

12. Escalation

13. Monitoring

Measure Target Frequency Owner If not met
Queue log extract (last 30 days) with arrival and seen times 100% of patients logged Monthly Reception lead Re-train; review staffing
Board updated within the set interval (spot check) 100% Monthly, 10 spot checks Reception lead Correct within the shift
Wait within target (90th percentile) Set by committee (EC) Monthly Service head Action plan after 2 months

14. Records

Record Kept in Retention
ACC-FRM-001 Queue Log Reception file 12 months, then archived for the period set by the facility’s records policy years
Monthly wait review (ACC-REG-001) Quality file the period set by the facility’s records policy years

15. Training

16. Related documents

ID Title Use
ACC-FRM-001 Queue Log Used in steps 2 and 4
ACC-REG-001 Monthly Wait-Time Review Used in step 5
SOP-077 Triage Protocol (generic) Urgent patients
INC-POL-002 Complaints and Feedback Route for complaints

17. Evidence

Reference Note
E-009 ASF Expert Committee consensus. Wait targets and update intervals are EC decisions.

18. Change history

Version Date What changed Approval
1.0 the date of approval First version Approved by the ASF Expert Committee
1.1 the date of approval Internal quality review: corrected cross-references, status wording and document control Approved by the ASF Expert Committee

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