Standards › Standard 2A › Policies
Policy · GOV-POL-002 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.2
At a glance
- Behave with honesty, respect and care for patients and colleagues at all times.
- Report safety concerns, mistakes and harm at once.
- Declare any conflict of interest before it affects a decision.
- Protect patient and staff information.
- Speak up if you see behaviour that breaks this code, and you will be protected from retaliation.
- Stop and get help straight away if: you are asked to act against patient safety or this code. Do not do it. Report it through the speak-up procedure.
1. Purpose
To state the standards of personal and professional conduct expected of everyone who acts for the facility [E-006, EC].
2. Scope
| Applies to | All staff, students, volunteers, contractors and governing body members |
| Locations | Everywhere the person works for the facility, including remote and home visits |
| When | From the first day of engagement, and throughout |
| Does not apply to | Clinical standards of practice, which are set by the professional bodies and the clinical policies |
3. Definitions
| Term | Meaning |
|---|---|
| Conduct | How a person behaves at work, including in writing and online |
| Retaliation | Any action taken against a person for raising a concern in good faith |
4. Background
Patients and colleagues depend on people behaving reliably and honestly. A code of conduct sets the expectation, makes it clear what happens when it is broken, and protects people who speak up.
The code is the reference for criterion 2A.2 and is adapted from the ASF Policy Framework (Policy 16, Policy 67 and Form F12).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Every person covered | Read, sign and follow the code; report breaches | Induction |
| Managers | Model the code; act on concerns; keep records of breaches | Management training |
| HR lead | Keeps signed acknowledgements; runs the disciplinary process | HR competence |
| Chief executive | Approves the code and reports breaches to the governing body | Executive leadership |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Signed acknowledgement (FRM-N10) | Signed on engagement and after each change | Complete |
| Speak-up form (FRM-N04) | Current | Available to all |
7. Safety
- Do not share patient information outside the approved record, including on social media.
- Never accept gifts or favours that could influence your work above the limit in the gift policy.
8. Before you start
- Read the code before you start work.
- Sign the acknowledgement before you work alone.
9. Procedure
Step 1. Act with honesty and integrity.
- Tell the truth about your work, including mistakes.
- Do not falsify records, timesheets, certificates or claims.
Key point: Honesty is the basis for safety. A hidden mistake is a larger risk than a reported one.
Step 2. Treat everyone with respect.
- Do not discriminate on any ground, harass, bully or abuse a patient, relative or colleague.
- Use a professional tone in all communication.
Key point: Harm from disrespect is real, even if no one is physically hurt.
Step 3. Report safety concerns at once.
- Report any incident, near miss, unsafe condition or harm through INC-POL-001 on the same shift.
- Do not wait to be sure.
Key point: Reporting is a duty, not a judgment about a colleague.
Step 4. Declare conflicts of interest.
- Complete FRM-N01 on appointment and when a new interest arises.
- Declare before a decision, not after.
Key point: Conflicts that are declared can be managed. Undeclared ones damage trust.
Step 5. Protect information.
- Keep patient information confidential, follow the records and privacy policies, and do not share passwords.
- Report any breach at once through DIG-SOP-001.
Key point: Confidentiality is what allows patients to speak frankly.
Step 6. Speak up when you see a breach.
- Raise the concern with your manager or through the speak-up route (SOP-N21 and FRM-N04).
- Concerns raised in good faith are protected. Retaliation is a breach of this code.
Key point: People stay silent when they think nothing will change or that they will be punished. Both must be untrue here.
10. Decision points
- If the instruction you receive conflicts with patient safety, do not carry it out. Inform the most senior available clinician and record the conflict.
11. Special situations
| Situation | Action |
|---|---|
| Students and volunteers | Briefed on the code at induction; supervisors are responsible for compliance. |
12. Escalation
- Breaches are reported to the line manager; serious ones to the HR lead and the chief executive.
- A concern about a senior person goes to the chair of the governing body.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Signed acknowledgement on file for each person | 100% | Each engagement; yearly check | HR lead | Acknowledge within 14 days or stop access |
| Breaches reported and closed within 30 days | 90% (EC) | Quarterly | HR lead | Review by chief executive |
| Staff who can describe the speak-up route (sample) | 80% (EC) | Yearly | Quality lead | Briefing |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Signed acknowledgement (FRM-N10) | HR file | Duration of employment plus the period set by the facility’s records policy years |
| Breach records and outcomes | HR file (restricted) | the period set by the facility’s records policy years |
15. Training
- Code of conduct is covered at induction for every person (EC).
- Refresher each year and after any change (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| GOV-PLN-001 | Strategic Plan | The code is part of the plan |
| FRM-N10 | Policy Acknowledgement and Code of Conduct Declaration | Signed acknowledgement |
| FRM-N04 | Confidential Integrity Report (Speak-Up) | Speak-up form |
| SOP-N21 | Whistleblowing and Speak-Up Procedure | Speak-up route |
| SOP-N01 | Conflict of Interest and Impartiality Policy | Declarations |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version adapted from ASF Policy 16 | 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 |
E-learning for this document
- Quality Management in Healthcare (A-02)
- Safety Management System & Leadership (MGMT-01)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)