Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.4
At a glance
- Use the named structured tool for every handover between teams and shifts.
- Give the handover verbally, face to face or by phone.
- The receiver asks questions and confirms the plan back.
- Record the handover, the giver and the receiver.
- Stop and get help straight away if: a patient is transferred between teams with no handover given.
1. Purpose
To make sure every transfer of care between teams or shifts is complete, understood and confirmed (S1.4).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Handoffs lose information when they are unstructured. A structured handoff, with time for questions, keeps the plan and the risks.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Giver | Gives the structured handover; answers questions | Trained in the tool |
| Receiver | Asks questions; confirms the plan back | Trained in the tool |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Named structured handover tool | Current | On the wall of each handover area |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Prepare.
- Look at the record and the current risks before the handover.
Key point: Preparation is what makes it short.
Step 2. Give the handover.
- Cover the patient, the situation, the background, the assessment and the plan, in the tool order.
Key point: Use the tool every time, even when busy.
Step 3. Receive and question.
- Ask at least one question.
- Repeat back the plan and the risks.
Key point: A handover with no question is not finished.
Step 4. Record.
- Record the handover on HOS-FRM-004, with both names and the time.
Key point: The record shows who has the patient now.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Transfers with a recorded handover | 100% | Monthly | Ward manager | Escalate to clinical director |
| Observed handovers using the tool | At least 70% | Quarterly | Clinical governance lead | Retrain the team |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HOS-FRM-004 | Handover record | Record used in step 4 |
17. Evidence
| Reference | Note |
|---|---|
| E-007 | WHO Nine patient safety solutions (2007): communication during handovers. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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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)
- World Health Organization (2007). Nine patient safety solutions, including correct patient identification. Geneva: WHO. Open source (E-007)