Standards › Standard 2A › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · CON-SOP-002 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.8
At a glance
- Ask each inpatient, or each day-care patient, the structured questions before discharge or on the day of care.
- Record the answers on CON-FRM-004 with the date and service.
- Look at the answers each week in each service and act on any concern the same day.
- Summarise the answers every three months and report them to the governing body.
- Tell patients what changed because of their feedback.
- Stop and get help straight away if: a patient reports a safety concern or serious unhappiness. Pass it to the ward head at once and treat it as an incident or complaint.
1. Purpose
To learn about the patient’s experience while they are receiving care, so problems can be fixed before the patient leaves, not only through complaints after discharge [EC].
2. Scope
| Applies to | Inpatients and day-care patients at the facility |
| Locations | All wards and day-care areas |
| When | Before discharge or at the end of day-care, and at least once in each stay for stays longer than 3 days (EC) |
| Does not apply to | Formal complaints, which are handled under INC-POL-002 |
3. Definitions
| Term | Meaning |
|---|---|
| Structured feedback | Answers to a fixed set of questions asked in the same way each time |
| In-stay | While the patient is still receiving care |
4. Background
Complaints only capture what patients are willing to raise, after the event. Structured feedback during care finds problems while they can still be fixed. Criterion 2A.8 asks for this.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Nurse in charge or delegate | Asks the questions and records the answers | Trained in the questions and in responding to concerns |
| Ward or service head | Reviews answers weekly and acts on concerns | Management training |
| Patient representative | Reviews the summary and advises on improvement | Patient engagement |
| Quality lead | Analyses the summaries and reports to the governing body | Analysis competence |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Structured feedback form (CON-FRM-004) | Current version; in the languages patients use | Available at each ward |
| Feedback summary template (QUA-REG-002) | Current | Used quarterly |
7. Safety
- Do not ask questions in a way that makes the patient feel pressured or unsafe to answer.
- Keep answers confidential. Share only in summary.
8. Before you start
- Check the patient can understand the questions. Use an interpreter or a read-aloud option where needed.
- Explain that the answers help improve care and are not part of their treatment.
9. Procedure
Step 1. Ask the questions.
- Ask the questions on CON-FRM-004 in the patient’s language, or offer the form to complete alone.
- Allow the patient to decline any question.
- Do not ask in front of other patients where privacy is not possible.
Key point: The patient is free to answer honestly only when they are not pressured.
Step 2. Record the answers.
- Record each answer on CON-FRM-004 with the date, service and time.
- Record any concern verbatim.
Key point: Accurate answers are the basis for the summary. Do not interpret them while recording.
Step 3. Act on any concern the same day.
- If the patient reports a safety concern, pass it to the ward head at once.
- If the concern is about a clinical issue, the ward head informs the responsible clinician before discharge.
- Log the concern as an incident or complaint where it meets the policy.
Key point: The purpose of asking during care is to fix things during care.
Step 4. Review each week.
- The ward head reviews the week’s answers, looks for patterns, and agrees one or two actions.
- Record the actions on QUA-REG-002.
Key point: Weekly review turns answers into actions quickly.
Step 5. Summarise and report quarterly.
- Complete the quarterly summary (QUA-REG-002) with the number of responses, the main themes, and the actions taken.
- Report to the governing body with the patient representative’s comments.
Key point: The summary shows the governing body what patients say and what was done about it.
Step 6. Tell patients what changed.
- Publish a short “you said, we did” update on the ward notice board or the website every six months.
Key point: Patients who see their feedback acted on are more likely to give it.
10. Decision points
- If fewer than a set number of patients respond in a month, the ward head extends the sampling and records why (EC).
11. Special situations
| Situation | Action |
|---|---|
| Patients who cannot complete the form | Ask the questions verbally, with an interpreter if needed, and record the answers as given. |
| Children | Ask the parent or carer, and the child where appropriate (EC). |
12. Escalation
- Safety concerns go to the ward head at once.
- Any concern that suggests a patient has been treated unfairly goes to INC-POL-002.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Eligible patients asked the questions | 80% (EC) | Monthly | Ward head | Review of the process within 2 weeks |
| Concerns acted on the same day | 100% | Monthly | Ward head | Escalate to service head |
| Quarterly summary delivered to governing body | 100% | Quarterly | Quality lead | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| CON-FRM-004 Structured In-Stay Feedback Form | Ward file, anonymised after summary | Duration of the summary cycle plus the period set by the facility’s records policy years |
| Quarterly summary (QUA-REG-002) | Quality file | the period set by the facility’s records policy years |
15. Training
- Ward staff are trained in the questions, in privacy, and in responding to concerns (EC).
- Refresher each year.
16. Related documents
| ID | Title | Use |
|---|---|---|
| CON-FRM-004 | Structured In-Stay Feedback Form | Used in step 1 |
| QUA-REG-002 | Patient Feedback Summary | Used in step 5 |
| INC-POL-002 | Complaints and Feedback | Route for formal complaints |
| CON-POL-003 | Patient Council Terms of Reference | Council reviews the summary |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Survey coverage and timing 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 |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)