Standards › Standard S5 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · AMT-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S5 (Ambulance and patient transport), criterion S5.2
At a glance
- Use a partner operator only under a written agreement.
- Check the partner’s certificates before the first use and at each renewal.
- Set the standard each party must meet.
- Record the handover responsibilities for each transfer.
- Stop and get help straight away if: a partner aircraft, ambulance or escort is used with no signed agreement or with an expired certificate.
1. Purpose
To keep the standard of partner-provided transport the same as our own, and to keep the patient safe across the handover (S5.2).
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
When another company provides the aircraft, ambulance or escort, the patient is still in your care. A written agreement and checked certificates make sure each partner meets the same standard.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Accountable manager | Signs the agreement and approves each partner | Management |
| Dispatch lead | Checks certificates before use and keeps the register | Trained dispatcher |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Partner agreement (signed) | Current | On file |
| Partner certificate | Valid | Copy on file |
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. Agree.
- Sign a written agreement that sets the standards, the evidence of certification and the responsibility at each handover.
Key point: The agreement is the standard.
Step 2. Check evidence.
- Check the certificates for the aircraft, the vehicle, the crew and the escort before first use.
- Record the check on AMT-FRM-002.
Key point: The provider checks before use, not after.
Step 3. Use and renew.
- Check the certificates again at each renewal date.
- Stop using a partner whose certificate has expired.
Key point: Expired means not used.
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 |
|---|---|---|---|---|
| Partners with signed agreement before use | 100% | Quarterly | Accountable manager | Escalate to chief executive |
| Partner certificates valid at use | 100% | Monthly | Dispatch lead | Escalate to accountable manager |
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 |
|---|---|---|
| AMT-FRM-002 | Partner certificate check | Check form |
| AMT-REG-002 | Receiving service agreements 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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