Standards › Standard S3 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PHC-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S3 (Primary care practice), criterion S3.6
At a glance
- Review the register each quarter to find patients overdue for care.
- Record each gap in care with its owner.
- Act on each gap and check it closes.
- Report the gaps to the practice meeting.
- Stop and get help straight away if: gaps in care are found and not reviewed for six months.
1. Purpose
To use the practice’s own list to find patients who need care and to show where care is missing (S3.6).
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
A practice that does not look at its own list cannot find the patients who are overdue for care. Simple data on the register shows where care is missing.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Practice manager | Runs the quarterly review | Management |
| Clinical lead | Agrees actions for gaps | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
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. Run the review.
- Pull the list of patients overdue for each measure from the register.
Key point: Use the whole list, not a sample.
Step 2. Record the gaps.
- Enter each gap on PHC-REG-004 with an owner and a date.
Key point: A gap needs a name.
Step 3. Act and check.
- Contact the patients.
- Check each gap closes by its date.
Key point: Closure is the measure.
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 |
|---|---|---|---|---|
| Quarterly reviews done | 100% | Quarterly | Practice manager | Escalate to chief executive |
| Gaps with owner and date | 100% | Quarterly | Clinical lead | Escalate to clinical lead |
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 |
|---|---|---|
| PHC-REG-004 | Care gaps register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. |
| 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)
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