Standards › Standard 1 › Policies
Policy · CLN-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 1.1
At a glance
- Staffing is calculated from patient volume and acuity, not from a fixed roster.
- Skill mix is set for each shift, with a named senior clinician in charge.
- The calculation is reviewed each month and after any change in demand.
- Gaps are recorded and escalated the same shift.
- Stop and get help straight away if: a shift runs below the calculated safe level with no escalation recorded.
1. Purpose
To make sure there are enough staff with the right skills for the patients in the care area (1.1).
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
Too few nurses for the number of patients, or too few with the right skills, leads to missed care and avoidable harm. Staffing should be calculated from real demand, not from habit.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief nurse or clinical director | Owns the calculation and approves the skill mix | Management |
| Duty manager | Checks each shift against the calculation | Senior 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. Calculate.
- Use the patient numbers and acuity for the last 4 weeks to calculate the staff needed for each shift (CLN-FRM-001).
Key point: Calculated from real demand.
Step 2. Check each shift.
- Compare the rota with the calculation before each shift.
- Escalate any gap to the duty manager.
Key point: Gap found before the shift, not during.
Step 3. Review.
- Review the calculation each month and after any change in case mix.
Key point: The calculation follows the patients.
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 |
|---|---|---|---|---|
| Shifts at or above the calculated level | At least 90% | Monthly | Chief nurse | Escalate to chief executive |
| Gaps with escalation recorded | 100% | Monthly | Duty manager | Escalate to chief executive |
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 |
|---|---|---|
| CLN-FRM-001 | Staffing calculation record | Calculation |
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 |
E-learning for this document
- Correct Patient Identification (—)
- Patient Identification, Informed Consent and Patient Rights (T-07)
- Governance & Management (H-07)
- Care & Treatment: Clinical Standards for Accreditation (H-04)
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)