Standards › Standard 2A › Policies
Policy · GOV-POL-005 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.10
At a glance
- At least one patient or family representative has a written role in quality review or governance discussion.
- The representative is invited to quality meetings and receives the papers in advance.
- The representative can raise items and their input is recorded in the minutes.
- The facility reports back to the representative on what changed as a result.
- Stop and get help straight away if: a representative raises a concern that is not recorded or answered in writing.
1. Purpose
To make sure patients and families have a structured role in improving governance and quality, not only indirect input through complaints and surveys [E-006, EC].
2. Scope
| Applies to | The governing body, quality committee, and the representative(s) appointed |
| Locations | Governing body and quality committee meetings |
| When | At each scheduled meeting where quality and safety are discussed |
| Does not apply to | Individual patient complaints, which are handled under INC-POL-002 |
3. Definitions
| Term | Meaning |
|---|---|
| Representative | A patient, former patient or family member who has agreed to a structured role, with a written role description |
| Written role | A document setting out the representative’s duties, term, expenses and support |
4. Background
Patients and families see things staff may not see. Criterion 2A.10 asks for a structured role, which means a named person, a written role and a record of what they contributed.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Governing body | Agrees the written role and appoints the representative | Governance training |
| Quality lead | Invites the representative; sends papers; records input | Quality governance |
| Representative | Attends, prepares, raises patient and family views | Training and support (EC) |
| Chief executive | Responds in writing to the representative’s input | Executive leadership |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Written role description | Current; signed by the representative and the chair | Dated and signed |
| Attendance register (GOV-REG-004) | Current | Completed each meeting |
7. Safety
- The representative is bound by the confidentiality rules of the facility and must not disclose identifiable patient information.
- The representative is not required to disclose personal health details.
8. Before you start
- Send papers at least five working days before the meeting.
- Check the representative has any support they need, such as an interpreter or reimbursement of travel (EC).
9. Procedure
Step 1. Agree the written role.
- Write the role description: purpose, duties, term (for example two years), expenses, support, and confidentiality.
- The representative and the chair sign it.
Key point: A written role gives the representative standing and tells everyone what to expect.
Step 2. Invite and prepare the representative.
- Invite the representative to each quality and governance meeting where safety or quality is discussed.
- Send papers in plain language, with an explanation of technical terms.
- Offer a briefing before the first meeting.
Key point: A representative who cannot follow the papers cannot contribute.
Step 3. Record their input.
- Record each contribution in the minutes (GOV-FRM-003), with the response.
- Make sure the representative is asked for input on each agenda item where patients are affected.
Key point: If input is not in the minutes, it did not happen for the governing body.
Step 4. Respond in writing.
- The chief executive responds in writing to each concern or suggestion within 30 days.
- Explain what will change and what will not, with reasons.
Key point: A response is what makes the representative’s role matter.
Step 5. Report back to patients.
- Share the outcomes of the representative’s input with patients through the patient council and the notice board every six months.
Key point: Patients should see that their voice changed something.
Step 6. Review the role each year.
- Review the role description, the term and the support yearly with the representative.
- Record the review.
Key point: Roles that are not reviewed become decoration.
10. Decision points
- If the representative raises a concern about a patient safety matter, the chair ensures it is referred to the appropriate incident or complaint route the same day.
11. Special situations
| Situation | Action |
|---|---|
| No representative available | The governing body records the vacancy and the steps taken to recruit; the role is not filled by a staff member. |
12. Escalation
- Concerns that a representative is not being heard go to the chair of the governing body.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Representative appointed with written role | Yes | Yearly | Governance lead | Escalate to governing body |
| Meetings attended by the representative | 80% (EC) | Quarterly | Governance lead | Review invitations and support |
| Input recorded with a response | 100% | Each meeting | Governance lead | Chair reviews minutes |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Written role description | Governance file | Duration of role plus the period set by the facility’s records policy years |
| Attendance register (GOV-REG-004) | Governance file | the period set by the facility’s records policy years |
| Minutes with the representative’s input | Governance file | the period set by the facility’s records policy years |
15. Training
- Representatives receive a briefing on the facility, its governance and confidentiality before the first meeting (EC).
- Governance members are briefed on how to use patient input.
16. Related documents
| ID | Title | Use |
|---|---|---|
| CON-POL-003 | Patient Council Terms of Reference | Patient council works alongside the representative |
| GOV-REG-004 | Attendance Register | Attendance record |
| INC-POL-002 | Complaints and Feedback | Individual complaints route |
| GOV-POL-001 | Governing Body Terms of Reference | Authority |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. Term, expenses and number of representatives 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 Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)